adherence, is another shift. Initial studies indicate some promise to this strategy. 9 The impact it may have on <strong>ADAP</strong> remains uncertain. SIT could potentially create cost savings, as clients no longer use medications on a continuous basis. • Another concern facing <strong>ADAP</strong>s is the impact of hepatitis C co-infection. Up to 25% of HIV infected individuals are co-infected with HCV, the virus that causes the symptoms of hepatitis C. 10 State and local health department resources and infrastructure to test for and treat HCV vary greatly among states. The cost of HCV treatment for co-infected individuals will likely fall to <strong>ADAP</strong>s since few HCV specific treatment programs exist at the federal or state level. <strong>ADAP</strong>s must also continue to make decisions regarding medications that treat the side effects of HAART, including adding statins that reduce cholesterol, blood pressure medications, and diabetes medications. All of these could lead to an increase in 1 Office of Management and Budget, Historical Tables, Budget of the <strong>United</strong> States Government, Fiscal Year 2003, 2002. Available: www.whitehouse.gov/omb/budget/fy2003/budget.html. 2 The federal fiscal year runs from October 1st through September 30th. The <strong>ADAP</strong> fiscal year runs from April 1st through March 31st. State fiscal years will vary by state. Fiscal years referred to in this report are <strong>ADAP</strong> fiscal years unless otherwise noted. 3 The National Governors Association and The National Association of State Budget Officers (2001) The Fiscal Survey of States, 2001. Available: www.nasbo.org/Publications/ fiscsurv/fiscsurvdec2001.pdf. 4 Kaiser Family Foundation, Prescription Drug Trends: A Chartbook Update, November 2001. 5 For more information on the <strong>ADAP</strong> drug discount programs, see: Kaiser Family Foundation and the National Alliance of State and Territorial <strong>AIDS</strong> Directors, <strong>AIDS</strong> Drug Assistance Programs: Getting the Best Price, April 2002. 6 Red Book, Thomson Medical Economics, 2001. 38 the cost to <strong>ADAP</strong>s of maintaining individuals on HAART. • Finally, drug resistance and resistance testing present ongoing challenges. As genotypic and phenotypic testing 11 become more integrated into practice, <strong>ADAP</strong>s and other programs that serve uninsured and underinsured individuals with HIV must determine how to pay for them. Drug resistance presents another challenge in itself; as individuals become more resistant to medications it becomes more likely they will be on “salvage” therapy—regimens consisting of four or more drugs and sometimes more than one protease inhibitor to boost effectiveness. These factors have cost implications for <strong>ADAP</strong>s. <strong>ADAP</strong>s have always operated as part of a dynamic health care treatment and financing environment, subject to changes in both. The National <strong>ADAP</strong> Monitoring Project will continue to monitor the status of <strong>ADAP</strong>s and the factors identified above over the next year. 7 Unlike current antiretrovirals, fusion inhibitors work to prevent HIV from entering a CD4 cell. 8 Integrase inhibitors interfere with the enzyme integrase that assists HIV in binding its genetic material with that of the CD4 cell. 9 Altfeld, M, Dybul, M, Miller, V, “An STI Confab: Insights Into Treatment Interruptions for Patients with Early, Chronic, and Drug Resistance HIV Disease,” Physicians Research Network/PRN Notebook, September 2001. Available: www.prn.org/prn_nb_cntnt/vol6/num3/sti_frm.htm. 10 Centers for Disease Control and Prevention, Frequently Asked Questions About Co-infections with HIV and Hepatitis C, August 2001. 11 Resistance testing can show whether a person’s virus is likely to be suppressed by each anti-HIV drug. There are two different types of resistance tests: Genotypic tests look for genetic mutations that have been linked to drug resistance; Phenotypic tests assess how much of a drug is required to block viral activity.
Appendices