October 25, 2008
The AIDS Drug Assistance Program (ADAP) is a federal program set up in each state to ensure that those living with HIV who cannot cover the cost of their HIV medicines can still access those drugs. This public program is a lifeline for many low-income individuals. Federal money is used to support the programs while many states also contribute to their own ADAPs.
Due to tightened state budgets and other issues, ADAPs are faced with providing services to an ever-growing list of people in need. Since many cannot fully meet these needs, most ADAPs often limit eligibility on a first-come, first-served basis. This has caused some people who are at higher risk for progressing in their HIV disease to not start HIV therapy soon enough.
A poster at the joint 2008 ICAAC / IDSA in Washington, DC presented information from a study that looked at prioritizing enrollees by CD4 count when ADAPs are faced with limited resources. The study used demographic information from the Massachusetts ADAP. The average age of enrollees was 45, average CD4 count was 181, and men accounted for 78% of the study population. The average rate for applicants who enrolled was about 80 per month.
The researchers created a simulated model with characteristics of an ADAP that looked at minimizing the rate of adverse health events while containing costs. The model then tracked the possible health progression of HIV-positive patients. It first simulated an ADAP that handled all eligible individuals, and then simulated one with a fixed limit of 10% more on a wait list. They studied one group on a first-come, first-served (FCFS) basis to that of another group with considerations of their CD4 counts.
The model revealed that basing a person's eligibility on CD4 count rather than only on a FCFS basis resulted in lower rates of opportunistic infections and death. Those with lower CD4 counts (<200) spent much less time waiting to start their HIV therapy. Although those with CD4 counts of 201-350 generally waited longer to start their meds, results showed that this did not negatively affect their health outcomes.
This is a hypothetical model simulating a possible ADAP process. It's unknown how this would be used by ADAPs around the country. However, it does lay some interesting groundwork for looking at this issue of maximizing limited state resources.
It's important to note that the simulated model showed good results when comparing CD4 count first-served to FCFS. This approach is not as effective as an ADAP that can fully enroll all its eligible individuals. This reinforces that fact that this model is suggesting changes only for ADAPs with wait lists and continuing limited resources in serving people living with HIV.