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State AIDS Drug Assistance Programs: Equity and Efficiency in an Era of Rapidly Changing Treatment Standards

Johri, Mira PhD, MPH*†; David Paltiel, A. PhD; Goldie, Sue J. MD, MPH§; Freedberg, Kenneth A. MD, MSc§¶

Original Articles

Background.  The 54 state AIDS Drug Assistance Programs (ADAP) provide medications to HIV-infected persons with limited resources. Eligibility and coverage vary, raising concerns about health inequities.

Objective.  To compare the relative clinical and economic performance of ADAP programs.

Research Design.  A state-transition simulation model of HIV disease was used to explore the clinical consequences and lifetime costs associated with selected state policies. Clinical data came from the Multicenter AIDS Cohort Study, AIDS Clinical Trials Group Protocol 320, and other published randomized trials. Cost data came from the national AIDS Cost and Services Utilization Survey, and the 1999 Red Book. ADAP data came from National Association of State and Territorial AIDS Directors reports and interviews.

Measures.  Projected life expectancy, quality-adjusted life expectancy, total lifetime direct medical costs, cost-effectiveness in dollars per quality-adjusted life year (QALY) gained.

Results.  ADAPs vary considerably in terms of formulary policies, health outcomes, expected costs, and cost-efficiency. Conservative projections, based on a cohort with starting mean CD4 count of 250 cells/μL, yield life expectancies ranging from 5.36 to 6.81 life years (4.69–6.01 quality-adjusted life years [QALYs]). Total per person lifetime direct medical costs range from $81,200 to $112,700; higher costs reflect increased spending on medications. Expected costs per QALY gained range from $7000 to $28,000. Under pessimistic assumptions regarding initial CD4 counts, drug efficacy, and discounting, the most comprehensive policy remains below $33,000/QALY.

Conclusions.  Even the most comprehensive ADAPs constitute a cost-effective use of HIV care resources. A uniform, national ADAP formulary warrants consideration.

*From the Department of Health Administration, Faculty of Medicine, University of Montreal, Montreal, Quebec.

†From the Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec.

‡From the Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut.

§From the Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts.

¶From the Division of General Medicine and the Partners AIDS Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

Supported by the Centers for Disease Control and Prevention (Cooperative Agreement U64/CCU 114927); by the National Institute of Allergy and Infectious Diseases via grant RO1-AI42006 to the Cost-effectiveness of Preventing AIDS Complications (CEPAC) project and CFAR grant 1P30AI4285101A2; the Adult AIDS Clinical Trials Group of the National Institute of Allergy and Infectious Diseases (Cooperative Agreement U01 AI38838); the Societal Institute for the Mathematical Sciences (SIMS) via Grant DA 09531 from the National Institute on Drug Abuse; and the National Institute on Mental Health via grant MH56826 to the Yale Center for Interdisciplinary Research on AIDS.

Address correspondence and reprint requests to: Mira Johri, Department of Health Administration, Faculty of Medicine, University of Montreal, C.P. 6128, succ. Centre-Ville, Montréal, QC Canada H3C 3J7. E-mail:

Received April 5, 2001; initial review July 17, 2001; accepted December 20, 2001.

© 2002 Lippincott Williams & Wilkins, Inc.