title: Association between U.S. state AIDS Drug Assistance Program (ADAP) features and HIV antiretroviral therapy initiation, 2001-2009.
abstract: BACKGROUND
  U.S. state AIDS Drug Assistance Programs (ADAPs) are federally funded to provide antiretroviral therapy (ART) as the payer of last resort to eligible persons with HIV infection. States differ regarding their financial contributions to and ways of implementing these programs, and it remains unclear how this interstate variability affects HIV treatment outcomes.
  
  
  METHODS
  We analyzed data from HIV-infected individuals who were clinically-eligible for ART between 2001 and 2009 (i.e., a first reported CD4+ <350 cells/uL or AIDS-defining illness) from 14 U.S. cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Using propensity score matching and Cox regression, we assessed ART initiation (within 6 months following eligibility) and virologic suppression (within 1 year) based on differences in two state ADAP features: the amount of state funding in annual ADAP budgets and the implementation of waiting lists. We performed an a priori subgroup analysis in persons with a history of injection drug use (IDU).
  
  
  RESULTS
  Among 8,874 persons, 56% initiated ART within six months following eligibility. Persons living in states with no additional state contribution to the ADAP budget initiated ART on a less timely basis (hazard ratio [HR] 0.73, 95% CI 0.60-0.88). Living in a state with an ADAP waiting list was not associated with less timely initiation (HR 1.12, 95% CI 0.87-1.45). Neither additional state contributions nor waiting lists were significantly associated with virologic suppression. Persons with an IDU history initiated ART on a less timely basis (HR 0.67, 95% CI 0.47-0.95).
  
  
  CONCLUSIONS
  We found that living in states that did not contribute additionally to the ADAP budget was associated with delayed ART initiation when treatment was clinically indicated. Given the changing healthcare environment, continued assessment of the role of ADAPs and their features that facilitate prompt treatment is needed.
authors.affiliation: Johns Hopkins University, Baltimore, Maryland, United States of America ; Albert Einstein College of Medicine, Bronx, New York, United States of America.
authors.forename: David B
authors.initials: DB
authors.lastname: Hanna
authors.forename: Kate
authors.initials: K
authors.lastname: Buchacz
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Gebo
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Hessol
authors.forename: Michael A
authors.initials: MA
authors.lastname: Horberg
authors.forename: Lisa P
authors.initials: LP
authors.lastname: Jacobson
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Kirk
authors.forename: Mari M
authors.initials: MM
authors.lastname: Kitahata
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
authors.forename: Richard D
authors.initials: RD
authors.lastname: Moore
authors.forename: Sonia
authors.initials: S
authors.lastname: Napravnik
authors.forename: Pragna
authors.initials: P
authors.lastname: Patel
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Silverberg
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Sterling
authors.forename: James H
authors.initials: JH
authors.lastname: Willig
authors.forename: Ann
authors.initials: A
authors.lastname: Collier
authors.forename: Hasina
authors.initials: H
authors.lastname: Samji
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Thorne
authors.forename: Keri N
authors.initials: KN
authors.lastname: Althoff
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Martin
authors.forename: Benigno
authors.initials: B
authors.lastname: Rodriguez
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Stuart
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Gange
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy* / Q000191:economics*; D044966:Anti-Retroviral Agents / Q000008:administration & dosage* / Q000191:economics*; D002170:Canada; D005260:Female; D006078:Government Programs; D061889:Healthcare Financing; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014481:United States
chemical_list: D044966:Anti-Retroviral Agents