Background:  U.S. AIDS Drug Assistance Programs (ADAP) are in fiscal crisis. Many states have instituted wait-lists, serving clients on a first-come first-served (FCFS) basis without consideration of disease stage in the allocation process. The FCFS approach may lead to worse outcomes than would prioritizing patients with low CD4-counts. We hypothesized that, as compared with a FCFS approach, CD4-based eligibility would serve a more diverse population with significantly lower CD4 counts. Therefore, we estimated and compared clinical characteristics of ADAP enrollees under FCFS and CD4-based eligibility schemes.

Methods:  Retrospective analysis of the Massachusetts ADAP administrative dataset. We applied potential FCFS and CD4-based eligibility criteria to all fiscal year 2003 Massachusetts ADAP applicants to determine who would have been included in a limited program. We then assessed the CD4 counts and demographics of the populations under each eligibility scheme.

Results:  In fiscal year 2003, Massachusetts ADAP served 3560 clients with a direct program cost of $10.3 million. Had Massachusetts ADAP implemented a CD4-based eligibility scheme (eligible if current or nadir CD4 ≤350/mL), it would have served 2253 clients (37% fewer) with a savings of $2.8 million. The median CD4 count of those clients would have been 267/mL (inter-quartile range 142 to 386/mL). Given the same budget constraint (reduced by $2.8 million), had ADAP accepted applicants on a FCFS basis, the program would have served 2406 clients (32% fewer) with median CD4 count of 411/mL (inter-quartile range 243 to 627/mL). The FCFS approach would have excluded a population with median CD4 count of 257/mL (inter-quartile range 124 to 377/mL) in favor of a population with median CD4 count of 659/mL (inter-quartile range 511 to 841/mL) (see the figure). Compared to the FCFS approach, a CD4-based scheme would have served a significantly greater proportion of non-white individuals (65% vs 55% p <0.0001), non-English speakers (24% vs 20% p = 0.03), and people who are unemployed (69% vs 61% p = 0.0009).

Conclusions:  With limited resources, ADAP will serve more diverse and significantly more advanced HIV patients using CD4-based enrollment criteria rather than a FCFS approach.