1. Texas HIV Medication Program Dwayne Haught, MSN, ACRN May 31, 2007

2. Texas HIV Medication Program (THMP) Texas AIDS Drug Assistance Program (ADAP) Implemented 1987 RWCA Funded in 1990 4 th Largest ADAP in the USA Goal: “access to life sustaining medications for low income Texans with HIV”

3. Texas HIV Medication Program Budget ~ $82 Million/year Funding 60% Federal RW/40% State GR 14,909 clients served FY2006 Distribute meds through 450 community pharmacies in Texas Process > 1,000 prescriptions per day

4. Texas HIV Medication Program Eligibility Criteria Texas Resident HIV positive Low Income - < 200% of FPL $20,420/year single person Add $6,960 for each additional family member Uninsured/Underinsured for prescription medications

5. Demographics-Race/Ethnicity Source: THMP-HIV 2000 Texas-Texas Epidemiological Profile, 2006 THMP Clients Served in Q1 FY 2007 Compared to Persons Living with HIV/AIDS Texas

6. Demographics-Gender Source: THMP-HIV 2000 Texas-Texas Epidemiological Profile, 2006 Note: Transgender excluded (less than 1% of population) THMP Clients Served in Q1 FY 2007 Compared to Persons Living with HIV/AIDS Texas

7. Demographics N=9,859 Note: Transgender excluded (less than 1% of population) THMP Clients Served in Q1 FY 2007

8. Drug Expenditures by Class Total Expenditures: $81,971,352 (FY 2006)

9. Top Ten Drug Expenditures Quarter 1, Fiscal Year 2007

10. Texas HIV Medication Formulary Limited in scope Includes 43 medications in over 100 formulations/dosages All FDA approved ARVs 10 of 14 PHS recommended drugs to prevent and treat OIs

11. Issues and Trends 17% of new applications for services are coming from incarcerated populations 40% of new applicants report $0 income 73% of new applications report incomes of less than 100% FPL ($10,210/yr)

12. Issues and Trends Cost Containment More people alive with HIV today than ever before People staying on the program for much longer periods than previously Intense usage of the program/complex regimens

13. Issues and Trends Cost Containment Newer drugs with convenient dosing schedules, improved side effects, and different resistance profiles are brought to market at much higher prices Older drugs continue to rise in cost annually at twice the rate of inflation New classes of drugs have been much more expensive

14. Issues and Trends New Drug Classes Two new powerful ARV drugs are scheduled for release this year Both are New classes Integrase Inhibitor CCR5 Antagonist Both are oral Expect that they will have a huge impact on treatment regimens

15. Issues and Trends Resistance Resistance can be considered a natural response to the selective pressure of a drug Resistance forces changes to 2 nd and 3 rd line drugs/regimens $$$$$ more costly Limits future treatment options Some clients have run out of treatment options Drug resistant HIV is transmissible

16. Resistance HIV creates billions of new viruses in the body each day The goal of multi-drug tx is to reduce the amount of HIV in the body as low as possible Combination tx with a minimum of three drugs has been shown to be most effective

17. Resistance With billions of viruses being made every day, many random differences…. like mistakes can happen when any new virus is being made The mistakes/differences are mutations Mutations that change the parts of the virus where ARVs are meant to work can cause the virus to resist the drug

18. Resistance Drug resistance doesn’t happen because HIV is smart and figures a way to get around the drug Resistance mutations happen randomly Potent ARV combinations can reduce the amount of HIV in the body to very little

19. Resistance The less HIV being made in the body The less chance of random mutations happening The less mutations happening The less likely a drug resistant mutation will occur

20. Adherence Basically adherence is taking your drugs as prescribed Many studies are looking at the relationship between drug adherence and resistance If you take your drugs as scheduled can you develop resistance? How adherent do you need to be to prevent resistance?

21. Web Sites http://www.dshs.state.tx.us/hivstd/meds http://aidsinfo.nih.gov/guidelines/