Initiation and continuation of newer antiretroviral treatments among Medicaid recipients with AIDS

OBJECTIVE: To examine initiation of newer antiretroviral treatments across sociodemographic subgroups during the 3 years following the introduction of these treatments, and explore persistence on treatment and its association with patient characteristics. DESIGN: Merged Medicaid paid claims and HIV/AIDS surveillance data were used to analyze use of protease inhibitors (Pis) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) over time. Survival analysis techniques were used to analyze initiation of PI/NNRTI use. Ordinary least squares and logistic regression were used to determine predictors of persistence on PI/NNRTI therapy. SETTING AND PARTICIPANTS: The study population consisted of 2,459 New Jersey non-HMO adult Medicaid beneficiaries with AIDS, identified through a match between HIV/AIDS Registry and Medicaid files. Their PI/NNRTI use was followed from March 1996, when the first PI was licensed, to the end of 1998. MEASUREMENTS AND MAIN RESULTS: African Americans initiated treatment on average 8 months later than nonHispanic whites; initiation of treatment was also slower for injection drug users and for those who did not receive case management through a Medicaid waiver program. These bivariate findings were confirmed with a multivariate timeto-treatment analysis using proportional hazards regression. Among those initiating PI/NNRTI use, 35% had discontinued it by the end of follow-up. Bivariate analyses of treated individuals found that PI/NNRTI use as a proportion of follow-up time was lower for African Americans and Hispanics, and higher for older individuals and for those receiving case management through a Medicaid waiver program, while injection drug use history was not associated with persistence. These findings were confirmed by a regression analysis, which found that controlling for other characteristics, African-American race, and Hispanic ethnicity were each associated with a significant 8% reduction in the proportion of time on PI/NNRTIs following initiation of treatment. Alternative approaches for modeling persistence produced similar results. CONCLUSIONS: Results suggest that consistent longitudinal use is difficult for many patients. Persistence of use was lower for minority beneficiaries despite comparable coverage for pharmacy and other health services through Medicaid. Our findings suggest the need to examine nonfinancial barriers to appropriate use of highly active antiretroviral therapy, and to develop and test programmatic strategies for supporting patients in remaining on these regimens consistently.