摘要：Objectives. We sought state-level factors associated with the adoption of medications to treat mental health conditions on state formularies for the AIDS Drug Assistance Program. Methods. We interviewed 22 state and national program experts and identified 7 state-level factors: case burden, federal dollar-per-case Ryan White allocation size, political orientation, state wealth, passage of a mental health parity law, number of psychiatrists per population, and size of mental health budget. We then used survival analysis to test whether the factors were associated with faster adoption of psychotropic drugs from 1997 to 2008. Results. The relative size of a state's federal Ryan White HIV/AIDS Program allocation, the state's political orientation, and its concentration of psychiatrists were significantly associated with time-to-adoption of psychotropic drugs on state AIDS Drug Assistance Program formularies. Conclusions. Substantial heterogeneity exists across states in formulary adoption of drugs to treat mental illness. Understanding what factors contribute to variation in adoption is vital given the importance of treating mental health conditions as a component of comprehensive HIV care. As HIV care has changed from an acute to a chronic care model, providers and policymakers have recognized the need to treat mental health conditions among HIV-infected populations. HIV and mental illness are interrelated in several important ways. 1 Severe mental illness, particularly bipolar disorder and schizophrenia, may increase risk behavioral factors for HIV, thereby increasing the likelihood of infection. 2 – 5 Depression may worsen HIV disease, leading to conditions such as CD4+ T-lymphocyte count decline, increased incidence of AIDS-defining illness, and increased AIDS-related mortality. 6 – 9 Likewise, symptoms of HIV may overlap with somatic symptoms of depression, 10 , 11 the stigma and social effects of HIV may cause depression, 12 – 14 and depression may hamper adherence to the entire continuum of HIV care, including adherence to antiretroviral therapy. 15 – 19 One half of individuals in a nationally representative sample of HIV-infected individuals in the United States had a psychiatric disorder. 20 This prevalence may increase because new HIV infections disproportionately affect youth, women, individuals with lower socioeconomic status, and minorities. 1 Treating mental illness is therefore important not only as part of holistic care for HIV-infected individuals but also as part of improving HIV-related health outcomes. Approximately 30% of HIV-infected individuals in the United States receive antiretroviral medications through state AIDS Drug Assistance Programs (ADAPs), which are financed and maintained through the Ryan White HIV/AIDS Program (National ADAP Monitoring Project 2008). ADAPs, and Ryan White programs more generally, are “payers of last resort” for individuals who have gaps in private insurance coverage, who have not progressed to AIDS and thus do not meet Medicaid and Medicare disability requirements, or who do not meet Medicaid income requirements. 21 State Ryan White programs have considerable discretion in their program design; this flexibility allows state programs to respond to local needs and the changing HIV epidemic. 21 Some federal requirements exists, such as maintaining a minimum pharmaceutical formulary. 21 However, decisions on program enrollment, the breadth of reimbursable services and pharmaceuticals, and financing mechanisms are left to the states. The allocation of responsibility of ADAP management decisions to states has led to considerable interstate variation in program generosity, including the size and scope of drug formularies. Drug formularies vary widely, with some states covering primarily antiretrovirals and drugs to treat and prevent opportunistic infections, and other states maintaining unrestricted, open formularies. 22 Given the importance of treating mental health conditions as a component of comprehensive HIV care, it is noteworthy that some state ADAP formularies have been much quicker to add medications to treat these conditions. We examined whether there are factors associated with a state's adoption of psychotropic drugs. To generate hypotheses, we interviewed 22 state ADAP managers and other ADAP experts working at national organizations, in academia, for advocacy groups, and in the federal government. We identified a convenience sample of experts involved with state Ryan White programs in both early and later periods to explore factors related to program design over its history. Our sample also included state-level program staff from different geographic regions and some individuals with special expertise in ADAP funding to treat comorbid mental illness. On the basis of these interviews, we identified 7 state-level factors that we hypothesized could be associated with formulary adoption of psychotropic drugs: case burden, the size of federal dollar-per-case Ryan White allocations, political orientation, state wealth, passage of a mental health parity law, the number of psychiatrists per population, and the size of the mental health budget.
