Improving Outcomes in State AIDS Drug Assistance Programs

Background: State AIDS Drug Assistance Programs (ADAPs) provide antiretroviral medications to patients with no acccss 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 all 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 <= 350/mu L (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 <= 250/mu L led to lower 5-year mortality than FCFS eligibility (2.77 vs. 3.27 deaths per 1000 person-months) and to a lower incidence of first Opportunistic infection or death (5.55 vs. 6.98 events per 1000 person-months). CD4-based eligibility reduced the time to starting ART for patients with CD4 Counts :<= 200/mu L. In sensitivity analyses, CD4-based eligibility consistently led to lower morbidity and mortality than FCFS eligibility. Conclusion: When resources are limited, programs that provide ART call improve Outcomes by prioritizing patients with low CD4 Counts.