Abstract
BackgroundU.S. state AIDS Drug Assistance Programs (ADAPs) are federally funded to provide antiretroviral therapy (ART) as the payer of last resort to eligible persons with HIV infection. States differ regarding their financial contributions to and ways of implementing these programs, and it remains unclear how this interstate variability affects HIV treatment outcomes.MethodsWe analyzed data from HIV-infected individuals who were clinically-eligible for ART between 2001 and 2009 (i.e., a first reported CD4+ <350 cells/uL or AIDS-defining illness) from 14 U.S. cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Using propensity score matching and Cox regression, we assessed ART initiation (within 6 months following eligibility) and virologic suppression (within 1 year) based on differences in two state ADAP features: the amount of state funding in annual ADAP budgets and the implementation of waiting lists. We performed an a priori subgroup analysis in persons with a history of injection drug use (IDU).ResultsAmong 8,874 persons, 56% initiated ART within six months following eligibility. Persons living in states with no additional state contribution to the ADAP budget initiated ART on a less timely basis (hazard ratio [HR] 0.73, 95% CI 0.60–0.88). Living in a state with an ADAP waiting list was not associated with less timely initiation (HR 1.12, 95% CI 0.87–1.45). Neither additional state contributions nor waiting lists were significantly associated with virologic suppression. Persons with an IDU history initiated ART on a less timely basis (HR 0.67, 95% CI 0.47–0.95).ConclusionsWe found that living in states that did not contribute additionally to the ADAP budget was associated with delayed ART initiation when treatment was clinically indicated. Given the changing healthcare environment, continued assessment of the role of ADAPs and their features that facilitate prompt treatment is needed.
Highlights
Reducing HIV-related health disparities is a priority of the United States (U.S.) National HIV/AIDS Strategy (NHAS) [1]
Because we were interested in answering the question of whether individuals would have had different outcomes if they did not live in a state without a particular AIDS Drug Assistance Programs (ADAPs) characteristic, we limited certain analyses to a subset of individuals who lived in states with that particular feature in place at the time of antiretroviral therapy (ART) eligibility, and similar individuals who lived in states without that feature
To further explore the relationship between a state contribution to the annual ADAP budget and increases in ART initiation, we looked for evidence of a ‘‘dose-response’’ trend in state funding
Summary
Reducing HIV-related health disparities is a priority of the United States (U.S.) National HIV/AIDS Strategy (NHAS) [1]. ADAPs differ in many ways, including the additional criteria used to define who is eligible for ADAP assistance, the comprehensiveness of the state ADAP drug formulary, and the procurement of additional funding by the ADAP through sources such as state general revenue [14] This last factor is relevant because federal allocations may not cover the full needs of a state, and many states supplement the ADAP budget using monies from state funds, which in Fiscal Year 2011 made up 16% of the national ADAP budget [15]. U.S state AIDS Drug Assistance Programs (ADAPs) are federally funded to provide antiretroviral therapy (ART) as the payer of last resort to eligible persons with HIV infection. States differ regarding their financial contributions to and ways of implementing these programs, and it remains unclear how this interstate variability affects HIV treatment outcomes
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