Only four US state AIDS Drug Assistance Programmes cover all recommended cardiovascular risk-reduction therapies

The provision of medication to reduce the risk of cardiovascular disease by AIDS Drug Assistance Programs in the US is patchy and inconsistent, research published in the Journal of General Internal Medicine shows.

Only four state AIDS Drug Assistance Programs (ADAPs) provided medication that was consistent with national guidelines for the treatment of type-2 diabetes, hypertension, hyperlipidaemia and smoking cessation. Most states provided treatment that was at least partially compliant with guidelines for at least one of the risk factors, but a quarter of ADAPs provided no coverage at all.

“Our findings indicate that most ADAPs do not provide guideline-consistent prescription drug coverage for type-2 diabetes, hypertension, hyperlipidemia, or smoking cessation,” comment the investigators.

Cardiovascular disease is an increasingly important cause of serious illness and death in patients with HIV. Routine HIV care should include screening for cardiovascular risks so that appropriate medication can be offered to reduce the risk of disease and mortality.

Approximately a third of HIV-positive individuals in the US rely on their state ADAPs for their antiretroviral therapy. ADAPs are legally obliged to provide at least one drug in each antiretroviral class, but do not have to provide access to any additional therapies.

Many ADAPs provide neither treatment for hepatitis C nor HIV-related opportunistic infections. Investigators therefore wished to see if ADAP provision of therapies to reduce the risk of cardiovascular disease was consistent with national guidelines.

Their analysis was conducted in 2010 and included all 50 states as well as Washington DC, Puerto Rico and the US Virgin Islands.

Provision of cardiovascular therapies was categorised as consistent, partially consistent, or “no coverage” when compared to national guidelines.

Only four state ADAPs – Massachusetts, New Jersey, New York and Pennsylvania – provided prescription drug coverage consistent with guidelines for all four cardiovascular risk factors.

However, 68% of states and territories provided therapy that was at least partially consistent with guidance for one risk factor. No coverage was provided by 25% of ADAPs.

Analysis by risk factor showed that 28% of states provided therapy that was consistent with guidelines for type-2 diabetes, with a fifth of ADAPs giving access to treatment that was at least partially consistent with guidance. However, 51% of ADAPs provided no therapy for type-2 diabetes.

A quarter of ADAPs offered treatment for hypertension according to guidelines. A further 15% provided access to therapy that was at least partially compliant with guidance, but 60% did not provide risk-reduction therapy for high blood pressure.

In all 15% of ADAPs had treatment formularies that were consistent with national guidelines for hyperlipidaemia. The majority (53%) provided therapy that was partially consistent, but almost a third had no coverage.

ADAPs in only four states (8%) provided smoking-cessation therapy that was consistent with national guidance. Approximately half (47%) offered treatment that was partially compliant guideline, and 45% provided no access to this type of treatment.

“In our systematic survey of ADAP formularies, we identified only four states that provided prescription drug coverage consistent with clinical practice guidelines for all four modifiable cardiovascular risk factors,” write the investigators.

They believe that financial pressures and cost cutting could mean that some ADAPs are restricting their access to non-HIV medications. However, they note non-HIV drugs account for “less than 10% of the prescription drug budget.”

The researchers conclude that policymakers should address the “root causes” for the variations in coverage and “provide a comprehensive ADAP formulary informed by clinical guidelines.”

Blackstock OJ et al. State variation in AIDS Drug Assistance Progam prescription drug coverage for modifiable cardiovascular risk factors. J Gen Intern Med, online edition, doi: 10.1007/s11606-011-1807-5, 2011 (click here for the free abstract).