Texas Medicaid Skips Tests to Target AIDS Drugs

Some patients whose HIV dropped to undetectable levels in the mid- and late-1990s now find the virus on the rebound, resistant to one or more of the drugs in the combination previously so good at controlling them. But in the past few years, doctors have gained a new weapon in their arsenal -- two tests that determine which drugs will work and which will not. So indispensable have they become to AIDS practitioners that the Medicaid programs of 44 states cover both tests, and a 45th, Vermont, covers one. Texas is among the five states that don't cover either test; the others are Florida, Mississippi, New Jersey and Hawaii.

Drug-resistance tests come in two types -- a genotypic test, approved by the Food and Drug Administration (FDA), that identifies mutations in a patient's virus and can be used to predict drug resistance; and a phenotypic test, still under review by the FDA, that pits the patient's virus against antiviral drugs, giving doctors evidence which ones won't work. Both tests have their boosters, but an analysis of them presented recently at the retrovirus conference in Seattle endorsed genotypic testing. The genotypic testing, which provides faster results, is cheaper than phenotypic testing but still costs $300 to $600 per test. The phenotypic testing, considered easier to interpret, costs $800 to $1,000 per test.

The CDC plans to develop a system to track drug resistance and encourage the testing of newly diagnosed HIV patients, according to its five-year strategic prevention plan. The US Department of Health and Human Services now makes resistance testing the gold standard of care in its HIV treatment guidelines. Dr. John Hellerstedt, medical director of the Texas Medicaid program, suggested that genotypic testing may be approved for coverage as soon as May. "There are concerns about crafting a policy that ensures the tests aren't overused, and about the funding, of course," said Hellerstedt, whose Medicaid program is a division of the Texas Health and Human Services Commission. " All I can say for sure is that it'll be considered at our next two meetings, but my impression at this point is favorable."

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