The state of ADAP

The $1.43 billion AIDS Drug Assistance Program was in relatively good shape in 2007. For the first time ever, none of the states had waiting lists of patients for their individually run programs, though that lasted just a month and Montana currently has six people on its list.

The annual report on ADAP was prepared by the Kaiser Family Foundation and the National Alliance of State and Territorial AIDS Directors and released at a briefing in Washington, D.C. Tuesday, April 8.

"The ADAP safety net was initially started as an emergency measure to help states pay for medications but it has become part of the fabric of the way this nation deals with the AIDS epidemic," said Kaiser's Diane Rowland.

NASTAD's Julie Scofield said state ADAPs were able to serve more clients and offer more treatment options in 2007. That is because of changes in the way that Ryan White CARE Act funds are distributed, a real increase in supplemental funding, and the one-time impact of switching some patients to Medicare Part D programs.

A year ago the South Carolina ADAP program was in crisis with a waiting list of almost 600 patients. Local services organizations organized and brought public pressure to bear on the legislature, said Noreen O'Donnell, who administers the program.

The legislature responded by increasing its contribution to ADAP from $500,000 to $3.5 million. An additional $1 million was reprogrammed from other areas supported by Ryan White CARE Act funds. The waiting list disappeared.

Some states have found that picking up health insurance coverage for their clients with HIV can be a cost-effective move. But other smaller states simply do not have the administrative capacity to deal with the variety of insurance procedures and payments needed to implement that type of activity.

Under the reauthorized Ryan White program, state drug formularies must include at least one drug in each of the six classes of antiretroviral drugs used to treat HIV. All have met that requirement and have added the two new classes of drugs approved in 2007. Most states offer all of the drugs that the Food and Drug Administration has approved for treating the virus.

Despite the rosy report, the road ahead for ADAP is likely to have potholes. Two demographic factors are at work.

Estimates are that at least a quarter of those infected with HIV do not know it. The Centers for Disease Control and Prevention is rolling out programs to increase testing so that more people learn their status, and that will increase the demand for services, including ADAP.

Most Americans get their health insurance through the workplace. Rising unemployment means that more will losing that coverage and will be seeking help through government programs. And, the deteriorating economy means less tax revenue for state and the federal governments, crimping expenditures even further.

Douglas Morgan, who directs Ryan White programs at the U.S. Department of Health and Human Services, expressed concern about having sufficient numbers of adequately trained physicians to prescribe the often complex regimens needed to treat HIV. The shortages reflect broader trends in providing medical care in rural areas and in public health specialties. NASTAD's Murray Penner said, "Because of our fractured health care system, people are relying on [Ryan White programs] as their care," not as the stopgap program it was intended to be.

Congress seems likely to address overall health care reform in 2009. The final shape of those changes likely will have a significant impact on whether Ryan White continues to exist as a separate program or whether some or all of its functions are rolled into that reform package.