Underutilization of the AIDS Drug Assistance Program: associated factors and policy implications

Characterization of the Population Affected by the 6-Month Recertification Criterion of the Ryan White HIV/AIDS Program's AIDS Drug Assistance Program in Washington State, 2017-2019

INTRODUCTION

AIDS Drug Assistance Programs (ADAPs) provide financial support for medical care for people living with HIV (PLWH) in the United States. Federal policy requires that clients recertify for the program every 6 months, which has been described as a barrier to care access. Our objective was to describe the prevalence of and factors associated with ADAP disenrollment in Washington State.

METHODS

Between 2017 and 2019, we categorized ADAP clients by the success of their recertification applications as follows: (1) continuously enrolled, (2) ruled ineligible, or (3) disenrolled if they failed to recertify. We compared individuals who were disenrolled with those who were continuously enrolled by demographic and socioeconomic characteristics and engagement with case management using data from the Washington State HIV Surveillance and Ryan White data systems.

RESULTS

From 2017 to 2019, 5480 clients were enrolled in ADAP, of whom 1423 (26%) were disenrolled and 984 (18%) were ruled ineligible at least once. Compared with those who were continuously enrolled, disenrolled PLWH were more likely to be Black [unadjusted prevalence ratio (PR) vs White 1.31, 95% confidence interval (CI): 1.17 to 1.46], uninsured (PR vs private insurance 1.24, 95% CI: 1.10 to 1.40), and younger (PR 25-34 vs 35-44 years 1.23, 95% CI: 1.08 to 1.41). The median time to return after disenrollment was 12 months (95% CI: 8 to 19 months).

CONCLUSIONS

Disenrollment after failure to recertify was the most common reason why PLWH lost ADAP coverage in Washington State. ADAP recertification procedures disproportionately affect Black, young, and uninsured PLWH and may contribute to disparities in HIV outcomes.

Interstate data sharing of prescription drug monitoring programs and associated opioid prescriptions among patients with non-cancer chronic pain

All fifty states have implemented prescription drug monitoring programs (PDMPs) to reduce misuse and diversion of controlled drugs. Interstate PDMP data sharing has been called for by clinical practitioners, but evidence to support the effectiveness of PDMP data sharing is lacking. This study examined whether PDMP interstate data sharing with bordering states was associated with prescriptions of opioids. This was a cross-sectional study that included patients with non-cancer chronic pain from the 2014 National Ambulatory Medical Care Survey (weighted N = 66,198,751; unweighted N = 2846). Multinomial logistic regression was performed to examine the association between PDMP interstate data sharing status and patients' being prescribed opioids for pain treatment, controlling for covariates guided by the Eisenberg's model of physician decision-making. Findings indicated that patients residing in states with interstate PDMP data sharing with all or partial bordering states were not less likely to be prescribed opioids compared to those living in states without interstate data sharing. Other factors such as patient age, health insurance type, new patient status, and physician adoption of electronic medical records were associated with the likelihood of patients' being prescribed opioids. This study concluded that current practice of interstate PDMP data sharing with bordering states was not associated with patients' being prescribed opioids for non-cancer chronic pain treatment. Future studies and policy efforts that unravel technological, legal, and political barriers to reciprocal and equal interstate data sharing with bordering states should be warranted to inform PDMP redesign and in turn, augment overall PDMP effectiveness in reducing misuse of prescription opioids.

The Impact of State AIDS Drug Assistance Policies on Clinical and Economic Outcomes of People With HIV

We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.

Self-Report Measures in the Assessment of Antiretroviral Medication Adherence: Comparison with Medication Possession Ratio and HIV Viral Load

BACKGROUND

Adherence is a major determinant of the effectiveness of antiretroviral therapy (ART). We determined the association between self-reported adherence (SRA) and medication possession ratio (MPR), a pharmacy-based adherence measure, and their respective associations with viral load.

METHODS

Adherence to ART was assessed by MPR over 6 months and by self-report which included a question with a Likert-type scale response, a visual analogue scale (VAS), and an inquiry about the last time the patients skipped any prescribed medications.

RESULTS

Taking MPR as the "gold standard," all 3 SRA measures displayed high specificity but low sensitivity. The prevalence ratio (95% confidence interval) for viral load ≥50 copies/mL was 2.19 (1.07-4.50) for MPR <90%, 1.98 (1.04-3.78) for poor/fair/good versus excellent/very good ability to take antiretroviral drugs, 1.47 (0.79-2.75) for skipping medications within the past 2 weeks, and 2.51 (1.39-4.53) for VAS <95%.

CONCLUSION

These data suggest various SRA measures hold clinical value in screening for poor ART adherence.

Adherence among rural HIV-infected patients in the deep south: a comparison between single-tablet and multi-tablet once-daily regimens

BACKGROUND

Once-daily (QD), combination antiretroviral therapy (ART) can impact the willingness and ability of patients to take medications as directed. The impact of antiretroviral (ARV) drug adherence influenced by single-tablet (STR) versus multi-tablet regimens (MTR) among patients enrolled in the AIDS Drug Assistance Program (ADAP) in a rural environment has not yet been assessed.

MATERIAL AND METHODS

A retrospective chart review evaluated adherence and outcomes in adult HIV-infected patients enrolled in the ADAP at 2 ambulatory clinics in the Southeast, taking either a QD STR (efavirenz [EFV]/emtricitabine/tenofovir [TDF]) or a QD protease inhibitor (PI)-based, MTR (atazanavir [ATV], ritonavir [RTV], and emtricitabine/TDF) by evaluating pharmacy refill records, patient self-reported adherence, and virologic response.

RESULTS

A total of 389 patient records were analyzed (STR, n = 165 versus MTR, n = 224). There were more males, a higher percentage of treatment-naive patients, and more patients with a baseline CD4 count of >200 cells/mm(3) in the MTR group. Based on refill records, more patients on MTR were >90% adherent (61.6% versus 51.5%, P = .047). In a multivariable analysis, being treatment experienced was a negative predictor (odds ratio [OR] = 0.48, 0.29-0.78) for adherence. Regimen choice was not associated with adherence. More patients taking MTR were virologically suppressed at the end of the observation period. Regardless of the regimen, being >90% adherent was a significant predictor of virologic suppression (OR = 3.51, 1.98-6.23).

CONCLUSION

Treatment-experienced patients enrolled in ADAP are less likely to be adherent. A QD PI-based MTR may result in comparable adherence to an STR in a rural HIV-infected population.

Determinants of utilization of a no-cost HIV transition clinic: a cross-sectional study of young adults living with HIV/AIDS

There is minimal research that has been conducted among young adults to understand the determinants of the utilization of human immunodeficiency virus (HIV) health services in this population. The purpose of this study was to explore the levels and determinants of HIV transition clinic (HTC) services utilization by young adults living with HIV/acquired immunodeficiency syndrome (YALHA). The study used a cross-sectional design and quantitative methods to collect data from a sample of 379 YALHA between the ages of 15–24 years who were registered clients of an HTC in Uganda. During data analysis, utilization was categorized into two levels: regular (kept all appointment visits) and irregular (missed one or more appointment visits) utilization. Univariable, bivariable, and multivariable logistic regression analyses were used to examine the determinants associated with HTC utilization. The HTC services that were most utilized by the YALHA were those based at the clinic and provided by professional health care providers and these were: clinical examination (96%); laboratory services (87.1%); and counseling (69.7%). The services that were least utilized were home visiting (5.8%) and peer support services (19.8%). Of the 379 YALHA, only 32.4% regularly utilized the HTC. Multivariable analysis showed that the main determinants of HTC utilization were CD4 count category of ≥251/μL (adjusted odds ratio [AOR] =0.58, 95% confidence interval [CI] =0.36–0.95); not being on antiretroviral therapy (AOR =0.27, 95% CI =0.15–0.47); and not receiving counseling services (AOR =0.47, 95% CI =0.27–0.83). Regular utilization of the HTC by YALHA was low and utilization seems to be influenced by HIV infection stage and HIV counseling services, but not sociodemographic factors or community factors.

A qualitative study of underutilization of the AIDS drug assistance program

In our previous work, we demonstrated underutilization of the AIDS Drug Assistance Program (ADAP) at an HIV clinic in Alabama. In order to understand barriers and facilitators to utilization of ADAP, we conducted focus groups of ADAP enrollees. Focus groups were stratified by sex, race, and historical medication possession ratio as a measure of program utilization. We grouped factors according to the social-ecological model. We found that multiple levels of influence, including patient and clinic-related factors, influenced utilization of antiretroviral medications. Patients introduced issues that illustrated high-priority needs for ADAP policy and implementation, suggesting that in order to improve ADAP utilization, the following issues must be addressed: patient transportation, ADAP medication refill schedules and procedures, mailing of medications, and the ADAP recertification process. These findings can inform a strategy of approaches to improve ADAP utilization, which may have widespread implications for ADAP programs across the United States.

Association between U.S. state AIDS Drug Assistance Program (ADAP) features and HIV antiretroviral therapy initiation, 2001-2009

BACKGROUND

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.

METHODS

We 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).

RESULTS

Among 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).

CONCLUSIONS

We 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.

Personalized therapeutics: a potential threat to health equity

Throughout history, medical advances have been adopted first and preferentially by the well educated and economically advantaged groups. The development of personalized therapeutics holds promise to fundamentally alter the practice of clinical medicine, but if it also is used preferentially by economically advantaged groups, this advance will likely worsen socioeconomic disparities in health. Prospective development of strategies to ensure non- differential access to these therapies may help limit this unintended consequence of medical progress for economically disadvantaged groups.

Delayed entry into HIV medical care after HIV diagnosis: risk factors and research methods

Timely linkage to HIV medical care has the potential to improve individual health outcomes and prevent secondary HIV transmission. Recent research found that estimates of delayed care entry varied by study design, with higher estimates among studies using only HIV case surveillance data. In this analysis, we compared the prevalence and risk factors for care delay using data from two studies with different designs conducted in New York City. The Medical Monitoring Project (MMP) used a retrospective design to estimate historical delay among persons currently receiving care, while the Never in Care (NIC) study used a prospective design to estimate current delay status among persons who were care-naive at baseline. Of 513 MMP subjects in 2007-2008, 23% had delayed care entry greater than three months after diagnosis. Independent risk factors for care delay were earlier year of diagnosis and testing positive in a nonmedical environment. Of 28 NIC subjects in 2008-2010, over half had tested positive in a nonmedical environment. The primary-stated reasons for delay were the same in both studies: denial of HIV status and lack of perceived need for medical care. The strengths and weaknesses of surveillance only, prospective, and retrospective study designs with respect to investigating this issue are explored. Future studies and interventions should be mindful of the common selection biases and measurement limitations with each design. A triangulation of estimates from varying designs is suggested for accurately measuring care linkage efforts over time.