Texas Medicaid Program Considers Adding HIV Drug Resistance Testing Coverage

Texas is considering proposals to add coverage for antiretroviral drug resistance testing to its Medicaid program, the Houston Chronicle reports. Forty-four states cover both genotypic and phenotypic resistance testing under Medicaid, but Texas, along with several other states, does not cover either test. Drug resistance has become a problem in recent years, as patients' viruses have mutated, rendering antiretroviral drugs less effective; 87% of people on a multi-drug treatment regimen demonstrated signs of resistance to at least one antiretroviral drug in one study and 20% of newly diagnosed people have a form of HIV that is already resistant to at least one drug, according to another study. Genotypic testing, which has received FDA approval, identifies mutations in the virus to predict which antiretroviral drugs the person's virus may resist, while phenotypic testing, which is still under FDA review, tests a patient's virus against individual antiretroviral drugs. Genotypic testing, which was endorsed at a recent conference in Seattle, produces faster results, and at $300 to $600 per test, compared to $800 to $1,000 per test for phenotypic testing, genotypic testing is cheaper. However, the tests are more difficult to interpret than phenotypic testing.

Gaining Support
A number of doctors have been lobbying Texas to include resistance testing under its Medicaid program, the top insurer of people with AIDS. "It's important that Texas cover the tests. Without them, doctors are forced to treat patients by trial and error, wasting thousands of dollars on medications that don't work and contributing to the virus' evolving ability to resist treatment," Dr. Shannon Schrader, a Houston-area infectious disease specialist who focuses on patients with HIV, explained. Dr. Jospeh Gathe, another Houston-based infectious disease specialist, noted that doctors typically try three new drugs when one combination fails because they are not sure to which drug the patient has grown resistant. However, Dr. Wayne Shandara, a Baylor University medical professor who also works at the Thomas Street Clinic in Houston, said doctors should be able to "predict the appropriate drugs" if they are familiar with a patient's history. "I'm not sure Texas is backward on this. If these tests are covered by Medicaid and widely available, they undoubtedly will be used inappropriately and constitute a terrible waste of money -- money that could be better spent on other treatment or research, say, involving early detection," he added. Dr. John Hellerstedt, medical director of the state's Medicaid program, has been holding hearings on the tests for the past few months. Although there are "concerns about crafting a policy that ensures the tests are not overused and about funding," Hellerstedt suggested that genotypic testing may be approved as early as next month. "All I can say for sure is that it'll be considered at our next two meetings, but my impression at this point is favorable" (Ackerman, Houston Chronicle, 4/14).