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

描述(由申请人提供)： 艾滋病药物援助计划(ADAP)是由联邦政府资助的、由州政府管理的计划，主要为低收入、保险不足或未参保的艾滋病毒感染者提供药物“安全网”。根据财政资格标准、成本控制措施以及与抗病毒疗法、机会性感染预防和成瘾治疗有关的药物处方的包容性，各州的ADAP可能有所不同。国家ADAP政策的这些变化可能会导致类似的艾滋病毒感染者因居住状态的不同而产生不同的健康结果。这项研究的目的是确定1998至2008年间美国艾滋病毒感染者中州ADAP的具体结构特征与个体水平临床结果之间的关联。这项研究将基于生活在25个州的人的数据，这些人是北美艾滋病研究和设计协作(NA-ACCORD)的一部分。这项研究的目标1将按居住州确定健康结果的异质性水平，包括启动HAART的人(根据临床指南有资格开始治疗的人)和一年的艾滋病毒病毒学应答和一年和三年的死亡率(启动HAART的人)，控制个人水平因素、州水平因素和日历时间。目的2将使用多水平建模策略，控制潜在的混杂因素，检查临床符合条件的人中启动HAART的选定状态ADAP结构特征之间的关联。最后，目标3将使用工具变量方法确定选定状态的ADAP结构特征与启动HAART的人的一年艾滋病毒病毒学应答和一年和三年死亡率之间的关联。将在现在和以前的吸毒者中进行分组分析，其中许多人是ADAP的客户，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，而由于丙型肝炎病毒感染和阿片成瘾等共病，他们的医疗需求更大。 公共卫生相关性： 需要流行病学数据来评估国家政策对艾滋病毒感染者临床结果的影响。由于各州决定了许多影响艾滋病毒感染者健康的政策，因此对国家艾滋病药物援助计划(ADAP)各种功能的临床有效性进行比较，可能有助于通过确定那些将死亡率等负面健康后果降至最低的政策来影响政策的变化。这些信息与公共卫生政策特别相关，因为ADAP的客户占美国所有接受治疗的艾滋病毒感染者的三分之一以上，其中许多人有非法药物滥用史。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: Epidemiologic data are needed to evaluate the effects of state policies on clinical outcomes in persons with HIV infection. Because individual states decide on many policies that affect the health of persons with HIV infection, comparisons of the clinical effectiveness of various features of state AIDS Drug Assistance Programs (ADAPs) may help to influence changes to policies by identifying those that minimize negative health consequences like mortality. Such information is especially relevant to public health policy since ADAP clients represent over one- third of all persons with HIV infection receiving care in the United States, many of whom have a history of illicit drug abuse.