Optimizing resource allocation in United States AIDS drug assistance programs

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. With use of CD4 cell count-based eligibility (with an eligibility criterion of a current or nadir CD4 cell count <= 350 cells/mu L), it would have served 2253 clients (37% fewer than in fiscal year 2003) and appreciated savings of $2.7 million. 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/mu L (interquartile range, 124-377 cells/mu L) in favor of serving patients with median CD4 cell count of 659 cells/mu L (interquartile range, 511-841 cells/mu L). In addition, a CD4 cell count-based scheme would have served a greater proportion of nonwhite individuals (65% vs. 55%;), non-English speakers (24% vs. 19%;), and unemployed people (69% vs. 61%;), P <.0001 Pp. 03 Pp. 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.