BACKGROUND: 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. OBJECTIVE: To determine ADAP eligibility criteria that minimize morbidity and mortality and contain costs. METHODS: 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 <or=350/microL (current standard) and (2) CD4 count prioritized eligibility for those with CD4 counts below a defined threshold. RESULTS: In the base case, prioritizing patients with CD4 counts <or=250/microL led to lower 5-year mortality than FCFS eligibility (2.77 vs. 3.27 deaths per 1,000 person-months) and to a lower incidence of first opportunistic infection or death (5.55 vs. 6.98 events per 1,000 person-months). CD4-based eligibility reduced the time to starting ART for patients with CD4 counts <or=200/microL. In sensitivity analyses, CD4-based eligibility consistently led to lower morbidity and mortality than FCFS eligibility. CONCLUSION: When resources are limited, programs that provide ART can improve outcomes by prioritizing patients with low CD4 counts.
BACKGROUND: 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. OBJECTIVE: To determine ADAP eligibility criteria that minimize morbidity and mortality and contain costs. METHODS: We used Discrete Event Simulation to model the progression of HIV-infectedpatients 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 <or=350/microL (current standard) and (2) CD4 count prioritized eligibility for those with CD4 counts below a defined threshold. RESULTS: In the base case, prioritizing patients with CD4 counts <or=250/microL led to lower 5-year mortality than FCFS eligibility (2.77 vs. 3.27 deaths per 1,000 person-months) and to a lower incidence of first opportunistic infection or death (5.55 vs. 6.98 events per 1,000 person-months). CD4-based eligibility reduced the time to starting ART for patients with CD4 counts <or=200/microL. In sensitivity analyses, CD4-based eligibility consistently led to lower morbidity and mortality than FCFS eligibility. CONCLUSION: When resources are limited, programs that provide ART can improve outcomes by prioritizing patients with low CD4 counts.
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