1. Assessing Linkage to Care by Linking Prescription
Filling Records from an AIDS Drug Assistance
Program to Laboratory Results from HIV/AIDS
Reporting System in Washington DC.
Gurung DK1, Bayone S1, Freehill G1, Griffin A1, Samala R1, Wu
C1, Rangarajan S2,3, Hader S1, Kamanu Elias N1, Weidle PJ3
1HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA), District of
Columbia Department of Health, Government of the District of Columbia,
Washington, DC.
2 Satyam Computer Services Limited, Atlanta, GA.
3Division of HIV/AIDS Prevention, CDC, Atlanta, GA.
Disclaimer: The findings and conclusions in this presentation are those of the authors and do not
necessarily represent the views of the Centers for Disease Control and Prevention or the DC Department
of Health.

2. Background
 The National AIDS Drug Assistance Program (ADAP) of
the Ryan White Comprehensive AIDS Resources
Emergency Act.
 Source of prescription drugs for people with HIV/AIDS
with limited or no insurance.
 More than one-third of all people with HIV in care.
 Nationally: has grown from 183,299 persons in 2007
to 213,764 in 2010
 Budget: ~$1.4 billion in 2007 - ~$1.8 billion in 2010
 DC ADAP (2007-2010) enrolled about 2,500 clients and provided
service to about 1,700 clients either by paying for all HIV drugs or
with insurance help (Co-pay, Premium)
NASTAD. National ADAP Monitoring Report. 2006-2011

3. ENROLLED CLIENTS VS SERVED CLIENTS
2007 to 2011
3,000
Total Enrolled Total Served
2,500
2,000
1,500
1,000
500
0
2007 2008 2009 2010 2011
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

4. National HIV/AIDS Strategy
(NHAS)
One of the primary goals:
• Increase access to care and optimize health
outcomes for people living with HIV.
• “Clinical care providers should ensure
that all eligible HIV-positive persons have
access to antiretroviral therapy.”
The White House, National HIV/AIDS Strategy for the United States 2010

5. Objective
 The objective of this analysis was to assess
how well the Washington DC AIDS Drug
Assistance Program (ADAP) identified clients
in need of antiretroviral therapy and the rate
and rapidity with which they started therapy.

6. DC DOH & CDC Collaboration
 In 2008, the Senior Deputy Director (Dr. Hader) of the
HIV/AIDS Administration of the Washington DC Department of
Health identified ADAP for review to better utilize routine
information.
 CDC’s rapid analysis of program data determined feasibility of
linking available databases with the goal to produce routine
reports to improve performance of the ADAP program.
 2008- 2009: DC DOH had more complete laboratory records
and transitioned to E-HARS for HIV reporting.
 2009-2010: CDC provided TA to develop a Microsoft
Application that linked ADAP enrollment data, service
utilization claims data and health outcome databases and
generated ADAP program evaluation reports

7. Methods
Microsoft Access application that merged data
from three primary sources:
 Service utilization database for client characteristics
 Data from Pharmacy Benefit Management System
managed by Emdeon
 Enrollment data managed by DC ADAP
 HIV/AIDS Reporting System (HARS) – laboratory
values for viral load and CD4 cell count.
 Name-based since November 2006
 Electronic HARS in 2009 which facilitated the
transfer of laboratory values
 Prescription claims data from pharmacy benefit
management system in the DC ADAP program.

8. Characterization of Laboratory Values
 CD4 and Viral Load characterized in clinically relevant
strata.
 CD4 categories (cells/µL):
 0 – 49
 50 – 199
 200 – 349
 350 – 499
 > 500
 Viral load categories (copies/ml):
 < 400
 401 – 999
 1,000 – 9,999
 10,000 – 99,999
 > 100,000

9. Identified Clients ‘at Risk’
 CD4 count < 350 cells/mm3
 Viral load > 1,000 copies/ml or missing
 Not on antiretroviral therapy in ADAP at time
of laboratory testing
*US DHHS guidelines consistently recommended to start ART for clients
with CD4 count <350 cells/mm3 between 2007 – 2010.
*Clients not on antiretroviral therapy in ADAP with viral load <1,000
copies/ml considered to likely be taking therapy from another source.

10. Results
Identify Clients with Indication for
Antiretroviral Therapy and Quantify
Time to Start Therapy

11. Washington DC Dept of Health ADAP
Volume of Laboratory Tests for Analysis
Year 2007 2008 2009 2010
ADAP Eligible Clients (n) 2022 2403 3212 3359
Viral load test done at least once, n (%) 801 (40) 980 (41) 1298 (40) 2157 (64)
CD4 test done at least once, n (%) 790 (39) 574 (24) 1212 (38) 2266 (67)
*Laboratory tests reflect those available in the database.
Other laboratory tests may have been completed, but not available to this analysis
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

12. Quantify CD4 Counts among those in
ADAP – 2007 to 2010
n = 394 n = 799
100%
90%
80%
70%
CD4 cells/mm3
60% >/=500
350-499
50% 200-349
50-199
40%
0-49
30%
20%
10%
0%
2007 2008 2009 2010 2007 2008 2009 2010
(n=552) (n=321) (n=837) (n=1719) (n=315) (n=286) (n=451) (n=1051)
On ART in ADAP Not on ART in ADAP
ART = antiretroviral therapy
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

13. Identify those not on ART in ADAP and
‘at Risk’ - 2010
Viral Load Tests done while NOT on ART in ADAP
Viral Load Total At Risk
CD4 count
(cells/mm3) <= 400 401 - 999 1000 - 9999 10000 - 99999 >= 100000 Missing
0 – 49 4 1 3 7 17 26 58 53
50 – 199 75 2 16 25 12 34 164 87
200 – 349 121 9 11 25 11 27 204 74
350 – 499 133 2 13 30 5 34 217
>= 500 305 9 21 20 2 51 408
Missing 25 2 8 5 5 0 45
Total 663 25 72 112 52 172 1096 214
ART = antiretroviral therapy
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

14. Patients in ADAP not on ART & ‘at Risk’
2007-2010
CD4 cell count (cells/mm3)
Number of people at
0 – 49 50 – 199 200 – 349 Risk
2007 34 46 28 108
2008 45 61 17 123
2009 42 73 44 159
2010 53 87 74 214
Total 174 267 163 604
A person was considered ‘at risk’ if:
•VL ≥ 1000 copies/ml
•CD4+ <350 cells/mm3
•Not on ART prior to lab test
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

15. Time from CD4 Count until Initiation of ART
in ADAP for ‘at Risk’ Patients - 2007-2010
Year Eligible to Started
start ART
ART in Time from CD4 cell count until Started ART in ADAP (Days)
ADAP
N (%) Median IQR Range <30 31 – 60 > 60
2007 108 67 (62) 8 0-28.5 0-197 52 9 6
2008 123 47 (38) 14 5-46 0-309 31 7 9
2009 159 81 (51) 11 1-21.5 0-119 67 10 4
2010 214 106 (50) 10 0-21 0-167 96 4 6
Total 604 301 (50) 208 30 25
ART = antiretroviral therapy
IQR = interquartile range
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

16. Strata of CD4 cell count who Initiated ART
in ADAP for ‘at Risk’ Patients - 2007-2010
CD4 count Eligible to start Started ART in ADAP
(cells/mm3) ART N (%)
(n)
0 – 49 174 78 (45)
50 – 199 267 135 (51)
200 – 349 163 88 (54)
Total 604 301 (50)
P = 0.12 for comparison of starting ART if CD4 count 0 – 49 vs 50 – 349
ART = antiretroviral therapy
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

17. ‘At Risk’ Patients not Started on ART in
ADAP - 2007-2010
Year Eligible to Not Started Pending2 Time from CD4 cell count until end date
start ART on ART in (<30 days) of eligibility in calendar year (Days)
ADAP1
N (%) N (%) Median IQR Range
2007 108 35 (32) 6 (6) 102 52-193 32-278
2008 123 71 (58) 5 (4) 138 80.5-201 30-364
2009 159 58 (36) 20 (13) 112 68-218 30-360
2010 214 87 (41) 21 (10) 149 75.5-254 31-357
Total 604 251 (42) 52 (9)
1Clients‘not started on antiretroviral therapy in ADAP’ may have received antiretroviral therapy
from other sources not captured in this analysis.
2Pending – Clients who had a CD4 cell count in December of the year, but had not started ART
by December 31 of that year.
ART = antiretroviral therapy
IQR = interquartile range
AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010

18. Limitations
• Clients ‘not started on antiretroviral therapy
in ADAP’ may have received antiretroviral
therapy from other sources not captured in
this analysis.
• Clients in ‘pending status’ to start ART may
have started ART in the next year.
• A small percentage of insurance clients who
receive premium assistance only, not copay
assistance, is unlikely to use DC ADAP
network pharmacies and therefore, their
claims do not exist in the claims data.

19. Conclusions
• Between 2007 – 2010, many ADAP clients
eligible for antiretroviral therapy started
therapy in ADAP documenting the utility of
this essential public drug assistance program
(ADAP).

20. Recommendation
• To improve utilization of antiretroviral therapy
within ADAP, barriers to starting antiretroviral
therapy for clients with low CD4 cell counts
and effective means to overcome them, such
as outreach services by case management
services or providers for access and linkage
to care, should be explored and
programmatically addressed.

21. Acknowledgements
Washington DC Department of Health Centers for Disease Control and Preveniton
Nnemdi Kamanu-Elias Paul J Weidle
Sonya Bayone David Fluker
Gunther Freehill A Danielle Iuliano
Angelique Griffin Siva Rangarajan
Damber Kumar Gurung Neha Shah
Tiffany Ojo-West
Rowena Samala
Charles Wu
Shannon Hader