Epidemiologic Evaluation of State AIDS Drug Assistance Program Features in the US

艾滋病药物援助计划（ADAP）是由联邦政府资助，州政府管理的计划，主要为低收入，保险不足或未保险的艾滋病毒感染者提供药物“安全网”。ADAP可能因州而异，具体取决于财务资格标准、成本控制措施以及抗病毒治疗、机会性感染预防和成瘾治疗方面药物处方集的包容性。州ADAP政策的这些变化可能导致相似的艾滋病毒感染者因其居住州而具有不同的健康结果。本研究的目的是确定1998年至2008年美国艾滋病毒感染者个体水平临床结局的州ADAP特定结构特征之间的关联。这项工作将根据居住在25个州的人的数据进行，这些人是北美艾滋病队列研究和设计合作组织（NA-ACCORD）的成员。本研究的目的1将确定居住州在HAART启动（根据临床指南有资格开始治疗的人）和1年HIV病毒学应答以及1年和3年死亡率（启动HAART的人）方面健康结局的异质性水平，控制个人水平因素，州水平因素和日历时间。目的2将使用多层次建模策略，控制潜在的混杂因素，研究选定的状态ADAP结构特征与临床合格人群中HAART启动之间的关联。最后，目标3将使用工具变量方法确定选定状态ADAP结构特征与开始HAART的人的一年HIV病毒学应答和一年和三年死亡率之间的关联。亚组分析将在目前和以前的吸毒者中进行，其中许多人是ADAP客户，他们可能特别受益于ADAP服务，因为他们获得高质量护理的机会较少，并且由于丙型肝炎病毒感染和阿片类药物成瘾等并发症而产生更大的医疗需求。

AIDS Drug Assistance Programs (ADAPs) are federally-funded, state-administered programs that act as the drug "safety net" for primarily low-income, underinsured, or uninsured HIV- infected individuals. ADAPs may differ from state to state based on financial eligibility criteria, cost-containment measures, and inclusiveness of drug formularies with respect to antiviral therapies, opportunistic infection prophylaxis, and addiction treatment. These variations in state ADAP policies may result in similar HIV-infected persons having different health outcomes due to their state of residence. The objective of this research is to determine the association between specific structural features of state ADAPs on individual-level clinical outcomes among HIV-infected persons in the United States between 1998 and 2008. This will be conducted based on data from persons living in 25 states who are part of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Aim 1 of this research will determine the level of heterogeneity in health outcomes by state of residence with respect to HAART initiation (among those who are eligible for treatment initiation based on clinical guidelines) and one-year HIV virologic response and one- and three-year mortality (among those initiating HAART), controlling for individual-level factors, state-level factors, and calendar time. Aim 2 will examine the association between selected state ADAP structural features on HAART initiation among clinically eligible persons using multilevel modeling strategies, controlling for potential confounders. Finally, Aim 3 will determine the association between selected state ADAP structural features and one-year HIV virologic response and one- and three-year mortality among persons initiating HAART using instrumental variable methods. Subgroup analyses will be performed among current and former drug users, many of whom are ADAP clients and who may especially benefit from ADAP services given their lower access to quality care and greater medical needs as a consequence of co-morbidities such as hepatitis C virus infection and opioid addiction.