State AIDS Drug Assistance Programs (ADAPs) provide antiretroviral medications to patients with no access to medications. Resource constraints limit the ability of many ADAPs to meet demand for services.
To determine ADAP eligibility criteria that minimize morbidity and mortality and contain costs.
We used Discrete Event Simulation to model the progression of HIV-infected patients and track the utilization of an ADAP. Outcomes included 5-year mortality and incidence of first opportunistic infection or death and time to starting antiretroviral therapy (ART). We compared expected outcomes for 2 policies: (1) first-come first-served (FCFS) eligibility for all with CD4 count ≤350/μL (current standard) and (2) CD4 count prioritized eligibility for those with CD4 counts below a defined threshold.
In the base case, prioritizing patients with CD4 counts ≤250/μL led to lower 5-year mortality than FCFS eligibility (2.77 vs. 3.27 deaths per 1000 person-months) and to a lower incidence of first opportunistic infection or death (5.55 vs. 6.98 events per 1000 person-months). CD4-based eligibility reduced the time to starting ART for patients with CD4 counts ≤200/μL. In sensitivity analyses, CD4-based eligibility consistently led to lower morbidity and mortality than FCFS eligibility.
When resources are limited, programs that provide ART can improve outcomes by prioritizing patients with low CD4 counts.
From the *Divisions of General Medicine, Massachusetts General Hospital, Boston, MA; †Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ‡Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; §Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; ‖The Harvard Center for AIDS Research (CFAR), Harvard Medical School, Boston, MA; ¶Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA; and #Massachusetts Department of Public Health HIV/AIDS Bureau, Boston, MA.
Received for publication October 27, 2008; accepted March 9, 2009.
Supported by grants from the National Institute of Allergy and Infectious Diseases (K01AI073193, K24AI062476, R37AI42006, P30AI060354), the National Institute of Mental Health (R01MH073445), and by the Massachusetts Department of Public Health HIV/AIDS Bureau.
Presented at the Society for Medical Decision Making, October 21, 2008, Philadelphia, PA, and at the joint meeting of ICAAC/IDSA, October 25, 2008, Washington, DC.
Correspondence to: Benjamin P. Linas, MD, MPH, Massachusetts General Hospital, 50 Staniford St, Ninth Floor, Boston, MA 02115 (e-mail: firstname.lastname@example.org).