Optimizing Resource Allocation in United States AIDS Drug Assistance Programs
Divisions of 1General Medicine and 2Infectious Diseases and 3The Harvard Center for AIDS Research, Massachusetts General Hospital and Harvard Medical School, Departments of 4Biostatistics and 5Epidemiology, Boston University School of Public Health, and 6Massachusetts Department of Public Health AIDS Bureau, Boston, Massachusetts
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/μL), 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/μL (interquartile range, 124–377 cells/μL) in favor of serving patients with median CD4 cell count of 659 cells/μL (interquartile range, 511–841 cells/μL). 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%; 
), 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.
Received 31 March 2006; accepted 15 June 2006; electronically published 17 October 2006.
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(See the editorial commentary by Saag on pages 1365–7)
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Online publication date: 1-Jul-2009.
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Online publication date: 15-Nov-2006.