Acknowledgments This report,
and the series of reports produced by the ADAP Monitoring
Project, would not have been possible without the generous financial
support of the Henry J. Kaiser Family Foundation and its continuing role
as catalyst for informed dialogue on HIV/AIDS policy issues. The authors
would especially like to thank Dr. Sophia Chang, Jennifer Kates, Tim
Westmoreland and the staff of the Kaiser Family Foundation for their
support and guidance in shaping our project reports.
We are indebted to the members of the National Alliance of State and
Territorial AIDS Directors (NASTAD) and the AIDS drug assistance program
(ADAP) coordinators in every state for volunteering their time to
complete this national ADAP survey. Once again they proved to be
extraordinarily helpful in responding to the survey and follow-up
telephone calls.
We benefited greatly from the advice and suggestions provided by a
group of state AIDS directors and AIDS drug assistance program managers
who had the opportunity to review a draft of this report. They are:
Wendy Craytor (AK), Lanny Cross (NY), Thera Meehan (MA), Randall Pope
(MI) and Raleigh Watts (WA). Our thanks to them for devoting extra time
providing us with important feedback.
The principal authors of this report are Arnold Doyle, Richard
Jefferys, Joseph Kelly and Sasha Schamber. Antonie Auguste provided
research assistance and technical support.
Executive Summary State AIDS
Drug Assistance Programs (ADAPs) provide access to HIV/AIDS treatments
to low-income, uninsured and under-insured people living with HIV/AIDS.
ADAPs, authorized under Title II of the federal Ryan White Comprehensive
AIDS Resources Emergency (CARE) Act, are administered by each state and
territory that receives federal Ryan White Title II ADAP funds. Each
state determines program financial and medical eligibility criteria and
the number of treatments provided on its ADAP drug formulary. Each ADAP
operates within a unique state delivery and financing environment.
Consequently, these programs vary greatly by jurisdiction.
Since the introduction of combination antiretroviral therapy in late
1996, many ADAPs have been challenged to meet the demands of a rapidly
growing client population and increased monthly expenditures within the
context of finite program resources. While some states supplement
federal Ryan White ADAP monies with state general revenue funds, other
states do not provide any non-federal financing of their programs. In
addition, ADAPs in states with relatively limited Medicaid programs may
be shouldering an increased burden of low-income individuals living with
HIV/AIDS who do not meet restrictive Medicaid eligibility criteria.
In an effort to track the response of ADAPs to the rapidly changing
HIV/AIDS treatment environment, shifts in the demographics of the
HIV/AIDS epidemic, changes in funding sources, and to document program
variations across jurisdictions, the Henry J. Kaiser Family Foundation
commissioned the National Alliance of State and Territorial AIDS
Directors (NASTAD) and the AIDS Treatment Data Network (ATDN) to produce
a series of national ADAP status reports. The reports produced through
this effort, known as the National ADAP Monitoring Project, provide the
most up-to-date information on the fiscal, administrative and
programmatic status of the fifty-two state ADAPs.
The current report-the third in the series-is based on information
gathered from state AIDS program directors and ADAP coordinators through
a national ADAP survey. The survey was distributed to all ADAPs in
August 1998, and requested data on numerous aspects of each state ADAP
from the time period January 1, 1998 through June 30, 1998.
Data on number of clients served, program expenditures and number of
prescriptions filled were collected for January 1998 and June 1998. In
order to provide a picture of ADAP growth over a year, data from June
1998 were compared with data from July 1997 (presented in the March 1998
Interim Technical Report). While these data sets represent two discrete
points in time, it is important to note that ADAPs are constantly
evolving in an attempt to adapt to changes in the availability of
program resources, client demand and changes in HIV/AIDS treatment.
Fifty-one of the 52 jurisdictions responded by the survey deadline. The
major findings are as follows:
Clients Served The overall
number of clients served by ADAPs continues to increase nationally, with
most states experiencing increases and some states seeing declines in
the number of clients served between July 1997 and June 1998:
- State ADAPs served 53,765 clients nationally in June of 1998.
- The number of clients served by ADAPs increased by 22% nationally
among the 45 states reporting client and expenditure data in both June
1998 and July 1997 (47,814 compared to 39,106). When averaged out over
the eleven-month period, this represents an increase of 792 clients
per month nationally.
- Forty states reported increases in the number of clients served in
June 1998 compared with July 1997. Ten of these states reported
increases of 50% or more in the number of clients served during this
time period. Nine states reported decreases in the number of clients
served.
Expenditures Overall ADAP
program expenditures are growing at a fast rate, with large increases in
national spending on antiretroviral treatments and decreases in national
spending on drugs for the prevention and treatment of opportunistic
infections (OIs) and other formulary drugs. Since July 1997, program
expenditures have increased at a higher rate than the growth in the
number of clients served, largely reflecting an increase in the costs
and use of combination antiretroviral therapies recommended by
Department of Health and Human Services' guidelines:
- Overall ADAP expenditures in June 1998 were $40.8 million.
- National ADAP expenditures grew by 37% among the 45 states
reporting client and expenditure data in both periods ($35.7 million
in June 1998 compared to $26 million in July 1997).
- Forty-one states reported increases in monthly program
expenditures between July 1997 and June 1998. Eighteen of these states
reported expenditure increases of 50% or more between these two time
periods. Five states reported decreases in monthly expenditures
between these two periods.
- In June 1998, national per client ADAP expenditures (for the 45
states reporting client and expenditure data in both periods) were
$747 per client, compared to $665 in July 1997-a 12% increase.
- Antiretroviral (ARV) expenditures increased by 54% between June
1998 and July 1997 ($30.1 million compared to $19.6 million in the 38
states reporting data in both periods). Expenditures on antiretroviral
drugs, including protease inhibitors, comprised a growing proportion
of overall ADAP expenditures (88% in June 1998 compared to 78% in July
1997 for those states reporting data in both periods).
- Notably, national ADAP expenditures on OI and other formulary
drugs decreased by 31%, from $5.6 million in July 1997 to $3.8 million
in June 1998 (in the 33 states that cover OI drugs and reported data
for both periods). In addition, expenditures on OI/other drugs
comprised a decreasing proportion of overall ADAP expenditures (11% in
June 1998 compared to 22% in July 1997 among these 33 states).
- In June 1998, the number of prescriptions filled by ADAPs
nationally totaled 150,078.
- There was a 28% increase in the number of monthly prescriptions
filled by ADAPs nationally (147,563 in June 1998 compared to 115,419
in July 1997 among the 41 states that reported prescription and client
data for both periods). The number of protease inhibitor prescriptions
filled rose by 71% among the 38 states reporting these data in both
periods (34,708 in June 1998 compared to 20,247 in July 1997).
Demographic Characteristics of ADAP
Clients Most of the clients served by ADAPs are people of
color, are poor, and are uninsured. More focused studies need to be
conducted in order to determine whether ADAPs-and other publicly-funded
HIV care programs-are serving the populations most in need in their
jurisdictions:
- Forty percent of clients with HIV disease served by ADAPs
nationally are white, 30% African American, and 26% Hispanic.
Asian/Pacific Islanders and American Indians/Alaskan Natives each
comprise about 1% of the ADAP client population.
- Eighty percent of clients with HIV disease served by ADAPs have
reported incomes below 200% of the Federal Poverty Level. Forty-eight
percent of ADAP clients have reported incomes below 100% of the
Federal Poverty Level, including ten states in which two-thirds or
more of the ADAP client population earn less than 100% of the Federal
Poverty Level.
- The majority of ADAP clients lack other public or private health
insurance. Almost 6% of national ADAP clients are also Medicaid
beneficiaries, and 9% of national ADAP clients have private insurance
that provides some level of prescription drug coverage.
- For the first time, state ADAPs identified where clients receive
primary care services and the number of physicians prescribing
medications for ADAP clients. ADAP clients most often receive primary
care from public clinics/local health departments (38% of all clients)
and hospital-based clinics (33%). The number of physicians prescribing
medications for ADAP clients ranged from a low of seven physicians to
a high of 3,339 physicians among states. Notably, 40 states were able
to report this information which provides additional base data for
further assessments of quality of HIV care.
ADAP Budget The national budget
for ADAP in fiscal year (FY) 1998 is expected to total $510.2 million in
federal and state funding-an increase of $139.4 million (or 38%) over
the FY 1997 national ADAP budget.
- ADAP supplemental funding under Title II of the federal Ryan White
CARE Act increased by 71%, from $167 million in 1997 to $285.5 million
in 1998. The amount of federal Title II base funding allocated by
states to their ADAPs increased by 6%, to $71.9 million nationally.
- Forty states provided state general revenue support for their
ADAPs in FY 1998, for a total of $119.4 million nationally; this
represents a 22% increase over FY 1997 state general revenue
contributions to ADAPs. Twelve states do not provide funds
specifically for ADAP and therefore rely solely on federal funding to
provide ADAP services.
Administrative Changes/Cost-Savings
Strategies In an effort to more effectively manage program
costs, several states reported making changes in the administrative
structures of their ADAPs, and taking a more active role in negotiating
drug discounts:
- Three states modified their ADAPs' drug purchasing/distribution
systems in order to take advantage of a federal drug discount program.
Significant changes went into effect since the March 1998 Interim
Report in the administration of this federal discount program that
will allow more ADAPs to receive drug discounts.
- Recently, several ADAPs delayed adding a newly approved
antiretroviral drug to their formularies pending the outcome of
negotiations with the drug's manufacturer over the relatively high
cost of the product. The ADAPs were successful in negotiating an
additional discount/rebate on the drug for all ADAPs nationally.
ADAP Restrictions, Budget Shortages and
Unexpended Funds Notwithstanding increased federal and, in
some cases, state funding for ADAPs, 26 states reported that they are
facing special ADAP program restrictions and/or budget shortages due to
client demand and inadequate resources. Several other states reported
that they expect to have unexpended ADAP funds remaining at the end of
FY 1998:
- Eleven states reported capped program enrollments, i.e., limiting
the number of clients that can be served at one time. All eleven
maintain active waiting lists for clients to enter the program. The
number of individuals on these waiting lists totals over 2,500. Five
states reported monthly or yearly per capita expenditure caps.
- Six states have capped or restricted access to protease inhibitors
or other antiretrovirals and two states continue not to provide any
protease inhibitors due to budget constraints.
- Fourteen states reported that, based on budget projections, they
expected to exhaust their current ADAP operating budget prior to the
end of Ryan White FY 1998 (March 31, 1999).
- Eighteen states reported that they had unexpended ADAP funds
remaining in their ADAP budgets at the end of Ryan White FY 1997;
eleven of these states carried these funds over into their FY 1998
ADAP operating budgets. Nine states reported that they expect to have
unexpended funds-totaling an estimated $8.6 million
nationally-remaining in their ADAP budgets at the end of Ryan White FY
1998.
Trends in ADAP
Eligibility, Drug Formulary Coverage and Responsiveness to Evolving
Clinical Practice Changes in eligibility criteria, drug
formularies and education/outreach efforts reflect attempts by states to
respond to emerging clinical standards within varying levels of resource
constraints:
- Five states expanded their ADAP income eligibility since the last
annual report, including three states that raised their income
eligibility since the March 1998 Interim Technical Report. On the
other hand, two states reported lowering their financial eligibility
ceiling since the last annual report.
- When the first NASTAD/ATDN report was published in July 1997, only
two ADAPs reported covering all approved antiretroviral drugs. By
October 1998, 46 ADAPs provided coverage for all approved
antiretroviral treatments.
- Twenty-two states reported adding antiretroviral drugs to their
ADAP formularies since July 1997. Twenty-three states reported adding
drugs for the prevention and treatment of opportunistic infections and
other non-antiretroviral drugs to their formularies.
- While 21 states now cover ten or more of the 14 drugs strongly
recommended by the U.S. Public Health Service/Infectious Disease
Society of America (USPHS/IDSA) "Guidelines for the Prevention of
Opportunistic Infections for Persons Infected with HIV," the remaining
31 state ADAPs do not provide this level of coverage.
- Almost all states reported efforts to disseminate federal HIV
treatment guidelines to providers and consumers and to provide some
type of ongoing HIV treatment education, such as mailings to providers
and clients and instituting Drug Utilization Review (DUR) procedures.
The ADAP State by State Profile Table that begins on the next page
includes a synopsis of each ADAP's financial and medical eligibility
criteria, coverage of specific classes of drugs, FY 1998 federal/state
ADAP budget information, the recent number of clients served and a
listing of special ADAP program restrictions in place as of October
1998.
Introduction State ADAPs
continue to play a vital role in providing access to life sustaining
treatments for an increasing number of low-income, uninsured and
under-insured people living with HIV/AIDS. While ADAPs initially were
intended to provide a temporary safety net of medication coverage, they
are now being called upon-within the context of the broader Ryan White
care system and the state public health system-to be conduits into
ongoing primary care, a means of access to more comprehensive and
longer-term health care reimbursement options such as Medicaid and
private insurance, purveyors of clinical education to health care
providers and consumers, and coordinators of outreach to underserved
populations. 1999 may continue to see an expansion of ADAPs' role, with
significant new investment in these critical programs by the federal
government and increased attention to program achievements and
outcomes.
For the remainder of Ryan White FY 1998 and through FY 1999, the
variations and disparities among ADAPs will likely continue to be
evident. While ADAPs operate within broad federal guidelines and receive
the bulk of their funding from the federal government, states have
significant discretion in determining client eligibility, the scope of
the ADAP drug formulary and how treatments are purchased and delivered
to clients. The varying fiscal, political, geographical and economic
environments particular to each jurisdiction add to the heterogeneity of
state ADAPs-similar to the impact these factors have on state Medicaid
programs. Significant additional federal ADAP funds expected in FY 1999
are unlikely to ameliorate the existing variations and disparities among
ADAPs.
The past year has been a time of fiscal stability and even expansion
for some ADAPs, while others implemented or continued program
restrictions due to resource constraints. This year has also seen
continued rapid advances in the treatment of HIV/AIDS with new and
costly antiretroviral medications entering the market. ADAPs have been
challenged to keep pace with this rapidly changing treatment
environment, including efforts to expand their formularies, expand
eligibility/client access and provide ongoing provider and consumer
education. While most ADAPs now provide all approved anti-HIV drugs,
there continues to be significant variation among these programs in
their coverage of drugs for the prevention and treatment of
opportunistic infections.
National attention has focused on disparities in health outcomes
among racial/ethnic groups in the United States, especially African
Americans and Latinos. While AIDS death rates have declined among all
affected communities, African Americans and Latinos have not experienced
as great a decline in AIDS-related mortality as whites. While there is
some evidence that the disparities in death rate declines among these
populations are lessening in some areas of the United States,
disparities persist in other areas of the country. State and federal
public health programs, including Ryan White programs and ADAP, are
being called to greater accountability for their efforts to reach and
serve these communities.
This report-the third in a series produced under the National ADAP
Monitoring Project-provides updated information on the number of clients
served through ADAPs, program expenditures and an analysis of
utilization and expenditure trends. The report will also analyze current
program budgets and changes in ADAP funding categories. Modifications in
ADAP eligibility and drug formularies, and program responsiveness to
changing clinical standards of care will be presented. Given national
attention on disparities in health outcomes for minority populations,
this report will also include a discussion of the demographic make-up of
state ADAPs, including the race/ethnicity, gender, age, health status,
and economic status of the ADAP client population.
The ADAP Update Survey In August
1998, a national ADAP update survey was distributed to the fifty-two
jurisdictions receiving Ryan White CARE Act Title II ADAP funds. Survey
responses were collected and analyzed throughout September and October,
with significant follow-up conducted by phone. Fifty-one jurisdictions
responded to the survey; the state of Wyoming was unable to respond by
the survey deadline.
The survey was intended to collect updated information on ADAP client
utilization and monthly utilization trends, ADAP budgets, program
shortfalls and restrictions, changes in ADAP formularies and efforts to
respond to changing clinical practice standards. In addition to updating
the information contained in previous National Monitoring Project
reports, states were asked to provide detailed ADAP client demographic
information, client health status/CD4 measurements and an assessment of
where their ADAP clients were receiving primary care services.
The findings from this survey represent one point in time and
comparisons reflect data reported between two to three points in time.
ADAPs are dynamic programs and continue to change on a daily basis.
Up-to-date state-by-state ADAP information is available on the
Monitoring Project's website at: http://www.aidsinfonyc.org/adap/index.html.
Client Utilization and Drug
Expenditures: What's Been Happening With ADAP? Over the
past year, ADAPs have continued to experience growth in the number of
clients served and in monthly pharmaceutical expenditures. Between July
1997 and June 1998, program expenditures increased at a higher rate than
the growth in clients served. This higher growth in expenditures largely
reflects increases in the cost and use of combination antiretroviral
therapies. While overall ADAP program expenditures on formulary drugs
continued to increase, expenditures on drugs for the treatment and
prevention of opportunistic infections and other formulary drugs
decreased.
This section will discuss trends in the number of clients served per
month by ADAPs and trends in monthly expenditures on pharmaceuticals,
including comparing current utilization and expenditure data with
similar data from one year ago. This section will also highlight trends
in ADAP expenditures on antiretroviral drugs and drugs for the
prevention and treatment of opportunistic infections.
Trends in Clients Served and
Expenditures Nationally, states reported that ADAPs served
53,765 clients during June 1998. When compared to July 1997, the number
of clients served by ADAPs increased by 22% among the 45 states
reporting client and expenditure data in both periods (47,814 in June
1998 compared to 39,106 in July 1997), as shown in Figure 1. When
averaged out over the eleven-month period between July 1997 and June
1998, ADAPs experienced an increase of approximately 792 clients per
month nationally. Over the two-year period, since July 1996, client
utilization has increased by 71% (47,109 in June 1998 compared to 27,531
in July 1996 among those 43 states reporting expenditure and client data
in June 1998 and July 1996).
Forty states reported increases in the number of clients served
between July 1997 and June 1998 (among the 49 states reporting client
data in both time periods). Ten states reported increases of 50% or
more. Of those ten states, four (Alaska, Delaware, the District of
Columbia and Oregon) reported greater than 100% increases in the number
of clients served during the same time period. Nine states (Alabama,
Idaho, Mississippi, New Jersey, North Dakota, Rhode Island, South
Dakota, Vermont and Virginia) reported decreases in the number of
clients served during this same time period.
Overall, ADAP program expenditures in June 1998 were $40.8 million.
Monthly ADAP expenditures grew by 37% nationally among the 45 states
reporting client and expenditure data in both time periods ($35.7
million in June 1998 compared to $26 million in July 1997), as
illustrated above in Figure 2. Over the two-year period, ADAPs
experienced a 163% growth in monthly expenditures nationally among those
43 states reporting expenditure and client data in both June 1998 and
July 1996 ($35.3 million in June 1998 compared to $13.4 million in July
1996).
Forty-one states reported increases in monthly program expenditures
between July 1997 and June 1998 (among the 46 states reporting
expenditure data in both time periods). Eighteen states reported
increases in monthly program expenditures of 50% or more between these
two time periods; of these, seven states (Alaska, Delaware, Nevada,
North Carolina, Oregon, Vermont and West Virginia) reported increases of
more than 100%. Five states (Alabama, Idaho, Iowa, Montana and New
Mexico) reported decreases in ADAP expenditures during this same time
period.
Nationally, per client ADAP expenditures were $747 in June 1998 and
$665 in July 1997, an increase of 12%. The average per capita
expenditure among ADAPs nationally during the same time period was $706
per month, or $8,472 annualized.
The primary component driving the increase in overall ADAP
expenditures is the significant rise in HIV antiretroviral expenses: an
increase of 54% between June 1998 ($30.1 million) and July 1997 ($19.6
million) among the 38 states reporting data in both periods. ADAP
expenditures for antiretroviral drugs (ARVs), including protease
inhibitors, comprised approximately 88% of June 1998 national ADAP
expenditures, compared with 78% of overall ADAP expenditures in July
1997. Per capita spending on ARVs increased by 26% during this time
period ($659 in June 1998 and $524 in July 1997) among these 38 states.
National ADAP expenditures on drugs for the treatment and prevention
of opportunistic infections and other formulary drugs decreased by 31%,
from $5.6 million in July 1997 to $3.8 million in June 1998, among the
33 states that cover OI drugs and reported data in both periods. In July
1997, OI/other drug expenditures comprised 22% of overall ADAP expenses
nationally; in June 1998, OI/other drugs accounted for approximately 11%
of overall ADAP expenditures (among these 33 states). Per capita
spending on OI/other drugs also decreased from $152 per ADAP client in
July 1997 to $86 in June 1998-a decrease of 43%. The decreases in
expenditures on OI/other drugs occurred despite the fact that many ADAPs
increased their coverage of these drugs over the past year. Further
research is needed to determine the exact reason(s) for the decline in
expenditures; however the decline may be due to increasing numbers of
ADAP clients utilizing combination antiretroviral therapy and subsequent
improvement in and/or maintenance of client health status.
The total number of prescriptions filled for all drugs on ADAP
formularies in June 1998 was 150,078. There was a 28% increase in
prescriptions filled among the 41 states that reported prescription and
client data in both June 1998 and July 1997 (from 115,419 in July 1997
to 147,563 in June 1998). The average number of prescriptions filled per
client remained relatively constant between July 1997 and June 1998-from
an average of 3.19 to 3.28 prescriptions per ADAP client. The number of
protease inhibitor (PI) prescriptions filled nationally between June
1998 (34,708) and July 1997 (20,247) increased by 71%. The percentage of
PI prescriptions filled by ADAPs nationally increased as well, with PIs
accounting for 24% of ADAP prescriptions filled in June 1998 compared to
18% of ADAP prescriptions filled in July 1997. The increase in PI
prescriptions may be the primary component of prescription expenditure
growth nationally among state ADAPs.
Appendix I
contains a state-by-state breakout of ADAP expenditures and
prescriptions filled. Expenditures and per capita spending on
antiretrovirals and OI/other drugs are delineated in Appendices II and
III. Appendix IV contains information on the number of protease
inhibitor prescriptions filled by state ADAPs. Each of these appendices
contains totals of all data reported by ADAPs as well as national
comparison totals that reflect data from only those states reporting in
both time periods.
Client Demographics: Who Is Served by
ADAP? Each year, federal, state and local governments
spend significant dollars to provide medical care to people living with
HIV/AIDS through publicly funded HIV care programs. While the recent
national decline in death rates may attest to the success of these
programs, an important-and as yet unanswered-question remains: To what
extent are publicly financed HIV care programs serving the populations
most in need? Persisting disparities in health outcomes for
racial/ethnic minorities-especially African Americans-demand that ADAPs
and other publicly funded HIV care programs carefully assess how and
whether they are meeting the needs of traditionally underserved
populations in their jurisdictions. This question should be posed not
only to ADAPs but also to state Medicaid programs, community health
centers and other publicly-funded sources of HIV care since, together,
they form the fractured continuum of care for the majority of people
living with HIV/AIDS in the U.S.
Answering this question at this time is methodologically complex.
First, there are currently no reliable estimates of the number of people
living with HIV at the national or state level-particularly by racial
and ethnic categories. While all states track AIDS cases, only 28 states
currently track adult HIV cases. Some of the states with the largest
ADAP populations and largest AIDS caseloads (e.g., California, New York)
are among those that do not have HIV case reporting systems. Yet ADAPs
serve both people with HIV without an AIDS diagnosis and those with
AIDS. In fact, these programs may be more likely to serve people with
HIV because those with an AIDS diagnosis are more likely to be eligible
for Medicaid. Therefore, the only available national data set against
which to compare ADAP demographic data-AIDS prevalence (reported living
AIDS case) data-provides an incomplete frame of reference.
Recently released data from the HIV Cost and Services Utilization
Study (HCSUS) provide detailed demographic information on a nationally
representative probability sample of people living with HIV, including
those with AIDS, in care. While these data may also be used as a point
of comparison, they too are limited in that they represent only
individuals living with HIV/AIDS that are in care, i.e., not all of the
HIV-infected population.
Secondly, ADAP is only one piece of a much larger financing
puzzle-one part of a health care payer system that includes Medicaid,
Medicare, other public health programs, private insurance and
pharmaceutical manufacturer-sponsored "charity" programs. An individual
who is not served by ADAP may be securing a portion or all of his/her
HIV treatments through any one of these other payers, or through a
combination of payers. Without looking at all pieces of this puzzle
together, it is impossible to draw conclusions about which demographic
groups may not have adequate access to needed services through any one
of these payers.
Despite these significant barriers, it is still critically important
to begin framing a response to the question posed above and to develop a
research agenda to explore this question more thoroughly. This section
attempts to begin such an assessment of ADAPs by providing a first
glance at the racial/ethnic, economic, gender and age characteristics of
the national ADAP population. The report compares national ADAP client
demographic data with the two data sets, albeit limited, mentioned above
- national AIDS prevalence data from the Centers for Disease Control and
Prevention (CDC) and HCSUS data. While the conclusions that can be drawn
from these comparisons are limited, they may assist states and
researchers in identifying areas for more detailed analysis.
Race/Ethnicity As discussed in
the introduction to this report, national attention has focused on
racial/ethnic disparities in health outcomes among people living with
HIV/AIDS and other chronic illnesses. ADAPs, other Ryan White programs,
and public and private health care systems are being called to
accountability for their efforts to reach and serve populations
disproportionately affected by the HIV/AIDS epidemic, particularly
African Americans.
States were asked to report the race/ethnicity of their ADAP clients
served in June 1998. Three state ADAPs (Louisiana, Nevada, New Mexico)
did not provide sufficient data to analyze the racial/ethnic make-up of
their client populations. However, the client population in this
analysis (N= 53,365) represents 99% of the total reported ADAP clients
served in June 1998.
Figure 3 As shown in Figure 3,
40% of the June 1998 ADAP population was reported as white/non-Hispanic,
30% as African American (black/non-Hispanic), and 26% as Hispanic.
Asian/Pacific Islanders and American Indians/Alaskan Natives each
comprised 1% of the utilizing ADAP population, and 2% were reported as
"other." When compared to data from the Health Resources and Services
Administration (HRSA) 1996 Ryan White Title II Annual Administrative
Report (AAR), there has been little change in the racial/ethnic
distribution of clients served by ADAPs over the last two years.
According to 1996 AAR data, whites comprised approximately 41% of the
utilizing ADAP population, African Americans 28%, Hispanics 25%, and
Asian/Pacific Islanders and American Indians/Alaskan Natives about 1%
each. The racial/ethnic distribution of the ADAP client population in
June 1998 varied significantly by state. A state-by-state breakout of
June 1998 ADAP client race/ethnicity is included in Appendix V.
Figure 4 When comparing these
data with AIDS prevalence data from the end of 1997 and with data from
the HCSUS study, differences between the three data sets emerge, as
shown in Figure 4. Whites account for 40% of reported living AIDS cases,
40% of the ADAP population and 49% of HIV-infected adults in care.
African Americans comprise 39% of reported living AIDS cases, 30% of the
ADAP population and 33% of adults in care. Hispanics represent 20% of
reported living AIDS cases, 26% of ADAP clients and 15% of HIV infected
adults in care. Asian/Pacific Islanders comprise 0.7% of reported living
AIDS cases, 1% of ADAP clients and about 1% of adults in care. American
Indians/Native Alaskans represent 0.3% of reported living AIDS cases,
0.6% of ADAP clients and 1% of adults in care.
Due to the limitations of the national data sets mentioned
previously, and the lack of data on other payers, the conclusions that
can be drawn from these comparisons are limited. This preliminary
presentation of the racial/ethnic make-up of state ADAPs should serve to
provide a starting point for further, more detailed research that takes
into account jurisdictional variations in the availability and
accessibility of other HIV care payers, the insurance status of affected
populations and other social, political and economic factors unique to
each jurisdiction.
Gender/Age States were asked to
provide data describing the gender and age characteristics of their ADAP
populations. Eighty percent of clients served nationally by ADAPs in
June 1998 were male, 20% were female. HRSA's 1996 Annual Administrative
Report (AAR) shows that of the total population served by ADAP during
calendar year 1996 (N=78,750), 79% of the clients were male and
approximately 18% were female (3% were reported as "unknown/missing").
This indicates little change in the national percentage of male and
female clients served through ADAPs in the past two years. AIDS
prevalence (living AIDS case) data also indicate that, nationally, 80%
of living AIDS cases are among males, 20% are among females.
Seventy-seven percent of the HCSUS survey population (individuals living
with HIV/AIDS in care) was male and 23% was female.
In 1997, the CDC reported that the number of AIDS deaths had fallen
for most demographic groups, but not for women. There was actually a
reported increase (3%) in the number of AIDS deaths among women during
this same time period. More recently, however, there have been reports
of decreases in the number of AIDS deaths among women. However, there
have also been reports indicating that women-especially poor, African
American women-comprise an increasing number of new HIV infections.
These data highlight the need for states to assess the disproportionate
impact that HIV may have on women in their jurisdictions, and-as with
racial/ethnic minority populations-to study the level and quality of
care that populations are receiving through ADAP and other publicly
funded HIV programs.
The overwhelming majority of clients (99%) who utilized ADAP services
during June 1998 were reported to be age 20 or above. The relative
dearth of clients below the age of 20 who are served by ADAPs is likely
attributable to the fact that infants and children with HIV/AIDS can
generally access more comprehensive healthcare services through
Medicaid. State-by-state information on ADAP client gender and age is
included in Appendix VI.
Client Health Status/CD4
Counts In order to make a preliminary assessment of the
health status of the national ADAP population, states were asked to
provide, within a given range, the CD4 counts of their currently
utilizing ADAP population. Thirty states, representing 62% (N=33,067) of
the June 1998 utilizing client population, provided CD4 data. Notably,
only about half of the states reporting CD4 data also reported that
these data were updated periodically, as opposed to being collected only
at the time of client enrollment.
Figure 5 As shown in Figure 5,
38% of the clients were reported to have CD4 counts of less than 200,
42% were reported in the 200-500 CD4 range and approximately 20% of
clients were reported to have CD4 counts above 500. There is some
significant variation among states in terms of the reported CD4
distribution of their ADAP populations. However, due to the fact that
much of these data may have been collected at an unspecified time in the
past, it is difficult to draw any conclusions regarding the health
status of the current ADAP population. Furthermore, since many ADAPs do
not regularly collect and update CD4 count data, more focused
studies-perhaps including studies of ADAP client medical records-are
needed to determine the health status of this population. State-by-state
ADAP client CD4 ranges are in Appendix VII.
Economic Status/Income
Levels States were asked to report the income levels,
within a given range, of their June 1998 ADAP clients served. Income
ranges were based upon percentages of the Federal Poverty Level (FPL)
for 1998. Eight states did not provide sufficient data to analyze client
income status. However, client income information was provided for 95%
(N=50,927) of the reported June 1998 ADAP clients served. National ADAP
client income level data are presented in Figure 6:
Figure 6 ADAP clients are
relatively poor with 48% percent having reported incomes below 100% of
FPL. Thirty-two percent of ADAP clients had reported incomes between
101-200% of FPL, indicating that 80% of June 1998 utilizing clients had
incomes below 200% of FPL. Eleven percent of clients had reported
incomes in the 201-300% FPL range, about 5% in the 301-400% FPL range,
and less than 2% had reported incomes above 400% of FPL. A comparison
with income level data from clients served by ADAPs nationally in July
1997 shows negligible changes in the reported income status of the
national ADAP population over the past year.
Appendix
VIII includes a state-by-state breakout of ADAP client income
levels. This appendix also shows the upper ADAP financial eligibility
and Medicaid eligibility limit for coverage under categorical
disability. While the upper ADAP financial eligibility limit varies from
a low of 100% of FPL to a high of over 400% of FPL, the Medicaid
financial eligibility ceiling is 75% of FPL-around $503 per month (or
lower) in every state. The question persists as to the degree of impact
that state Medicaid coverage has on ADAPs. While Medicaid financial
eligibility is relatively low in all states, 48% of ADAP clients
nationally have reported incomes below 100% of FPL. Ten states reported
that two thirds or more of their ADAP client populations had incomes
below 100% of FPL. These states are: Alaska (93%), Arkansas (100%),
Florida (75%), Georgia (73%), Kentucky (68%), Mississippi (80%), North
Carolina (85%), South Carolina (75%), South Dakota (80%), and West
Virginia (70%). Based on income criteria alone, many ADAP clients in
these states-and nationally-could be eligible for Medicaid services if
they also met the disability or other categorical eligibility
requirements. However, all of these states have "limited" or less
expansive Medicaid coverage, as described in an analysis of the impact
of Medicaid coverage on state ADAPs presented in the March 1998 Interim
Technical Report, perhaps limiting the ability of potential clients to
enroll in the Medicaid program.
Notably, all ten states referenced above also reported some type of
ADAP limitation/shortfall. While additional focused analysis needs to be
conducted in this area, research suggests that limited Medicaid coverage
in a state may cause low-income clients with HIV disease to be more
reliant on ADAP for accessing prescription drugs.
Medicaid/Insurance Status What
percentage of the national ADAP population has some level of
prescription drug coverage through private insurance or is covered by
Medicaid? Forty-eight states, representing 98% (N=52,775) of the June
1998 ADAP clients served provided data on client Medicaid/insurance
status. These data indicate that approximately 6% of the national ADAP
client population in June were also Medicaid beneficiaries, and over 9%
of national ADAP clients had private insurance that provided some level
of prescription drug coverage. Data from the March 1998 Interim
Technical Report indicate that 7% of the July 1997 national utilizing
ADAP population were on Medicaid and that 7% had private insurance.
In a few states, the reported percentage of clients with some level
of drug coverage through commercial insurance is relatively high,
including Minnesota (73%) and Oregon (70%). These states have
well-established insurance continuation/purchasing programs that
facilitate access to HIV primary care services in addition to HIV
treatments. These states pay only a portion of the costs of drugs for
large numbers of their ADAP clients who have prescription drug coverage
through commercial or high-risk pool insurance plans.
HIV Primary Care Sites and ADAP Prescribing
Physicians A critical question that remains unanswered is
exactly where ADAP clients receive their primary care. Access to
prescriptions is clearly sufficient to drive the continuing growth in
the ADAP client population, but access to prescriptions cannot be
interpreted as a marker for access to regular, quality care. While this
section provides a preliminary overview of care sites of ADAP clients,
it cannot provide information about the quality of care received by
clients.
The ideal way to comprehensively analyze the care received by ADAP
clients would be to collect data on health outcomes. Washington State,
for example, is conducting an ongoing review of ADAP client health
records in order to determine whether individuals are receiving the
standard of HIV care. As yet unpublished data from the HCSUS study may
also permit a national analysis of the health status of individuals in
HIV care, including ADAP clients.
In order to identify where ADAP clients receive primary care
services, states were asked to estimate what percentage of their ADAP
client populations receive primary care services at each of the
following sites: hospital-based clinics, private community-based
clinics, public clinics/local health departments, private
physician/physician group, or other sites. There was notable diversity
among ADAPs.
Figure 7 As shown in Figure 7,
ADAP clients receive primary care from public clinics/local health
departments (38%), followed by hospital-based clinics (33%), private
physicians (13%), private community-based clinics (11%) and "other"
sites (5%).
Colorado, Delaware, Michigan, Mississippi, Nebraska, New Jersey,
North Dakota, Utah, and Vermont reported that more than 75% of their
clients receive primary care at hospital-based clinics. Notably, in
Colorado, Delaware, Nebraska and Utah, large university hospitals
purchase and distribute treatments to ADAP clients on behalf of the
state health department (the Ryan White Title II/ADAP grantee).
Arizona, Florida, Nevada, and Puerto Rico indicated that 75% or more
of their ADAP clients receive primary care from public clinics. Montana
reported that 75% of its ADAP clients receive primary medical care at
private community-based clinics. Idaho reported that 75% of its clients
receive primary medical care from private physicians.
To provide additional base data for further assessment of quality of
care issues, states were also asked to estimate the number of physicians
who currently prescribe treatments for their ADAP client population. Ten
states did not provide these data; however, data were available for
approximately 67% (N=35,945) of June 1998 utilizing ADAP clients. The
number of physicians prescribing medications for ADAP clients ranged
from a low of seven physicians in Montana to a high of 3,339 physicians
in New York State. As expected, small states with relatively few ADAP
clients reported a relatively small number of ADAP prescribing
physicians, while larger ADAPs reported a relatively high number of
prescribers. Complete state-by-state information on primary care sites
and ADAP prescribing physicians is contained in Appendix
IX.
ADAP Budget Update: How Is ADAP
Funded? The national ADAP budget continues to expand. In
FY 1998, the national ADAP budget is expected to total $510.2 million in
federal and state funding. This represents an increase of $139.4 million
over the FY 1997 total of $370.8 million or a 38% increase. This section
will present the components of the national ADAP budget and trends in
budget growth over the past several years. The section will also
describe ADAP programmatic changes and cost-saving strategies, and will
present program limitations, projected budget shortfalls and projected
unexpended funds.
The national ADAP budget in FY 1998 consists of $390.8 million
(76.6%) in federal contributions and a state share of $119.4 million
(23.4%). The proportion of federal to state funding remained relatively
unchanged compared with FY 1997. However, Ryan White Title II ADAP
supplemental funding represented a larger share in the national ADAP
budget (45% in FY 1997 to 56% in FY 1998). Figure 8 shows the breakout
of the 1998 ADAP budget:
Figure 8 : Federal Funding for
ADAP ADAP supplemental funding increased from $167 million
in FY 1997 to $285.5 million in FY 1998 - a 71% increase. The growth in
overall ADAP budgets since FY 1996 nationally is being driven primarily
by growth in federal appropriations for ADAP supplemental funding.
Federal ADAP supplemental funding is expected to remain the most
critical component of ADAP budgets in FY 1999. Beginning in April 1999,
the federal ADAP supplemental budget will be $461 million, a $175.5
million increase over FY 1998. Figure 9 illustrates the relative changes
in ADAP budget categories between FY 1996 and FY 1998.
Figure 9 All but three states
(Massachusetts, Nebraska and West Virginia) experienced increases in
their federal/state ADAP budgets between FY 1997 and FY 1998. Fifteen
states saw increases of greater than 50% in their federal/state ADAP
budgets in the last year. These states were: Alabama, Arizona, Colorado,
Georgia, Idaho, Illinois, Iowa, Kansas, Kentucky, Maryland, Michigan,
Minnesota, Mississippi, New Mexico and Wisconsin. Nebraska and West
Virginia reported significantly decreased contributions to ADAP from
their states' Ryan White Title II base grants, likely due to the
significant increase in ADAP supplemental dollars.
Aside from the ADAP supplemental funding, the other federal ADAP
budget categories received only modest increases and one significant
decrease in FY 1998. The funds states elect to devote to ADAP from their
Ryan White Title II base funding increased by $4.3 million (6%) to $71.9
million nationally. Funding from Ryan White Title I Eligible
Metropolitan Areas (EMAs) increased by $2.6 million (11%) to $26.8
million in FY 1998. The number of EMAs contributing funds directly to
support their state's ADAP remained constant at 13, although the
constellation changed slightly. The Title I EMA in Cleveland, OH was
added to the list of contributing Title I areas in FY 1998, while
Portland, OR fell from the list. The Title I EMAs in New York State -
most significantly New York City - continued to account for the majority
(69%) of the nation's Title I contributions to ADAP. Funds identified as
"other federal funds" decreased by 53% to $7.3 million in FY 1998. These
largely included prior year funds that were approved as carry-over funds
into the FY 1998 fiscal year for state ADAPs.
State Funding for
ADAP Individual state contributions to ADAP represent the
widest degree of change in FY 1998 with significant fluctuations in many
areas. Forty states now supplement federal funds with state-specific
financial support for ADAP - a net increase of four states since FY
1997. There was a 22% increase over FY 1997 in state general revenue
contributions to ADAPs nationally. Five states provided contributions in
FY 1998 that did not provide funds in FY 1997. These states were Idaho,
Kansas, Mississippi, New Hampshire and North Dakota.
Twenty states provided increased general revenue support to their
ADAPs. Most notably, six states more than doubled their state ADAP
contributions in FY 1998 (Arizona, Colorado, Florida, Georgia, Indiana,
Missouri and New Mexico). On the other hand, six jurisdictions reported
reductions in ADAP funding from their state/locality in the last year
(District of Columbia, Hawaii, Illinois, Massachusetts, New Jersey and
Puerto Rico). Eight states provided level funding support to their ADAPs
in FY 1998 (Connecticut, Maine, Maryland, Minnesota, Nevada, Texas, Utah
and West Virginia). Twelve states do not provide funds specifically for
ADAP and therefore rely solely on federal funding to provide ADAP
services. These 12 states are: Alaska, Arkansas, Delaware, Iowa,
Michigan, Montana, Nebraska, Oregon, Rhode Island, South Dakota,
Tennessee and Wyoming.
Federal and state contributions to each state ADAP are listed in Appendix X, with
comparisons between FY 1997 and FY 1998 funding listed in Appendix XI.
State general revenue contributions to ADAP are contained in Appendix XII.
Half of all ADAPs (26 states) draw upon additional sources of funding
to supplement their budgets, although these other sources are chiefly
used to recover costs and are not uniformly used by all states. These
additional cost recovery mechanisms include obtaining rebates from
pharmaceutical companies and private health insurance recovery, and
accounted for $46.8 million in FY 1998. The largest portion of this
comes from drug rebates ($33.6 million or 71.8%). A state-by-state
breakout of these other budget sources is in Appendix
XIII.
ADAP Cost Recovery Resources |
Source |
Funding |
% of total |
Drug Rebates |
$33.6 million |
71.8% |
Insurance
Recovery |
$12.4 million |
26.5% |
Miscellaneous Other
Sources |
$.8 million |
1.7% |
Total Other Funds |
$46.8 million |
100% |
Including all sources (federal, state and cost recovery funds) the
total national ADAP budget increased from $402 million in FY 1997 to
$557 million in FY 1998.
Program Administrative
Changes During the past three years, ADAPs have attempted
to adjust to a rapidly changing treatment environment. In some cases,
states made significant structural changes in their ADAPs in order to
provide treatments in a more cost-effective and efficient manner.
Numerous states reported making administrative changes in their ADAPs
during the past year. In most cases, these changes were intended to
improve the operating efficiency, cost-effectiveness and data management
capabilities of the programs to adjust to changing conditions. Specific
state examples of program modifications include:
Program Administration Although
states can administer their ADAPs centrally or decentrally (i.e.,
contracting the administration of the program to an entity outside the
state government system), the vast majority of states administer their
programs centrally.
- California and Iowa completed the centralization of their ADAPs.
Previously, day-to-day administration of the California ADAP occurred
at the county level and Iowa ADAP was administered by the regional
Title II consortia.
- Louisiana decentralized its ADAP; the program is now administered
through ten regional medical centers that were part of the state
charity hospital system.
Drug Purchasing/Distribution
Systems ADAPs use a variety of systems to purchase and
distribute pharmaceuticals to clients. The type of drug
purchasing/distribution system that an ADAP uses determines the type of
drug-discounting strategy that the program can utilize.
- Iowa and Montana ADAPs began accessing the federal 340B (Public
Health Service) drug discount program by contracting with one retail
pharmacy outlet to provide ADAP services through the 340B contract
pharmacy mechanism.
- Kentucky ADAP contracted most of its drug purchasing/distribution
services to a local hospital that obtains federal 340B pricing.
- Connecticut, Vermont and West Virginia ADAPs converted from
time-consuming manual pharmacy billing systems to electronic,
point-of-sale (POS) billing systems.
Data Management ADAPs must
collect and manage significant amounts of data in order to track program
expenditures, develop budget projections and fulfill reporting
requirements.
- Connecticut, Louisiana, Michigan and Utah reported upgrading their
ADAP data collection and management capabilities.
Coordination with the State Medicaid
Program The March 1998 Interim Technical Report
highlighted the importance and cost-effectiveness of collaboration
between state ADAPs and their respective Medicaid programs. The Health
Resources and Services Administration (HRSA) and the Health Care
Financing Administration (HCFA), the federal agency that oversees the
Medicaid program, have encouraged cooperation and collaboration between
Ryan White programs-especially ADAPs-and state Medicaid programs.
- Connecticut, Florida, Kansas and South Carolina ADAPs reported
improved data-sharing and better overall coordination with their state
Medicaid offices.
- New York and Virginia ADAPs have implemented "back-billing"
systems with their Medicaid programs.
- Washington's ADAP has instituted a system whereby ADAP/Ryan White
clients in the Medicaid spenddown process have their total spenddown
liability reimbursed by the ADAP with state HIV dollars.
Cost-Saving Strategies
The 340B (PHS) Drug Discount
Program ADAPs have sought effective means of controlling
program costs-especially since the advent of combination therapy and the
subsequent increases in the number of clients served and monthly
pharmaceutical expenditures. The most proactive vehicles for ADAPs to
reduce monthly pharmaceutical costs are through participation in the
federal 340B (PHS) drug discount program or by obtaining voluntary
manufacturer rebates. Until recently, participation in the 340B drug
discount program was viable only for those ADAPs that act as direct drug
purchasers. However, on June 29, 1998, HRSA published new guidelines
that allow reimbursement-type ADAPs to obtain rebates through the 340B
program. Reimbursement-type ADAPs that elect to participate in the 340B
program rebate option are eligible to receive the same unit rebate
amount on purchased drugs as state Medicaid programs.
As of January 1999, 22 ADAPs had enrolled in the 340B program under
the new rebate option. Twenty-three ADAPs are currently enrolled as
direct purchasers. The remaining seven ADAPs are either planning to
enroll after April 1, 1999 (e.g., Maine, Missouri and Ohio), already
obtain rebates equal to or in excess of the 340B rebate percentage due
to favorable voluntary manufacturer rebate agreements (e.g., Michigan
and Minnesota) or ADAP rebate percentages are mandated by state law
(e.g., Pennsylvania).
Negotiation With Drug
Manufacturers As purchasers of care for relatively large
numbers of people with HIV/AIDS, state ADAPs have begun to play a more
central role in negotiations with the pharmaceutical industry regarding
drug cost/discount issues. Two examples highlight this trend:
- The 340B rebate option guidelines published by HRSA in June 1998
did not include specific steps for implementation of the rebate
mechanism. A workgroup of ten ADAPs, in collaboration with HRSA and
NASTAD, met and developed a set of implementation guidelines for the
340B rebate option called "Conditions of Participation." These
Conditions were shared with representatives of the pharmaceutical
industry-mainly major manufacturers of HIV/AIDS therapies-who provided
comment and feedback. The Conditions of Participation were revised to
address state and industry concerns.
- In September 1998, Dupont Pharmaceuticals received approval from
the Food and Drug Administration (FDA) to market a new anti-HIV drug,
efavirenz (Sustiva). The advertised wholesale cost of the new drug,
however, was approximately 50% higher than the other two approved
anti-HIV drugs in the same class (non-nucleoside reverse transcriptase
inhibitors, or NNRTIs). With several new HIV drugs slated for approval
in the coming year, some ADAPs became concerned about the
comparatively high cost of Sustiva and the potential for other
manufacturers to price their new products at the high end of the HIV
antiretroviral drug pricing spectrum. Several higher-volume ADAPs,
most in collaboration with local and national HIV community
organizations, decided to delay adding Sustiva to the state ADAP
formulary until Dupont Pharmaceuticals agreed to provide all ADAPs
with a greater discount/rebate than already mandated under the 340B
program. In response, Dupont did agree to offer all ADAPs an
additional 5% discount/rebate over the 340B price. This level of
involvement by a group of ADAPs to lower the final cost for a given
drug for all ADAPs nationally was unprecedented and it is an action
that is expected to continue.
Increasing Use of Insurance
Continuation/Purchasing Programs Several states have
well-established insurance continuation/purchasing programs that allow
them to more cost-effectively facilitate access to HIV care and
treatment for clients. Recent developments at the federal level will
likely increase the development and implementation of these
programs:
- Since FY 1996, Congress has set aside an ADAP "earmark" within the
Ryan White Title II allocation. HRSA has traditionally argued that
these earmarked funds be used solely for the purchase of FDA-approved
pharmaceuticals on the ADAP formulary. Several states have requested
greater flexibility in the use of these funds, including using a
portion to purchase and maintain insurance policies for ADAP clients,
thereby providing clients with a reimbursement source for both
pharmaceuticals and primary care services. During the FY 1999 federal
appropriations cycle, House and Senate appropriations committees
approved report language supporting the use of ADAP-earmarked funds
for the purchase and maintenance of health insurance policies that
provide adequate coverage for prescription drugs.
ADAP Restrictions, Budget Shortages and
Unexpended Funds Despite the growth in ADAP budgets
nationally, and the increased level of expenditures discussed earlier in
this report, there is substantial variation across state ADAPs in terms
of demand, client accessibility and services offered. There are states
with persistent program limitations, caps on new client enrollment,
waiting lists, budget shortages, and notable lack of state
contributions.
There are also a handful of states that are carrying unexpended
federal funds and are not currently using the full ADAP allocation.
Several of these states reported that they could more effectively use
the ADAP money for other purposes like insurance purchasing, often a
more cost-efficient means of providing client access to therapies and
primary care. There are also states that currently do not have a high
level of client demand. These states will likely be requesting
permission from HRSA, the federal agency that administers Ryan White, to
carry unexpended funds into the next fiscal year. These issues will be
discussed in more detail later in this section.
Current and Projected Program
Restrictions Twenty states are listed in one or more
current and/or projected ADAP program limitation categories:
- Eleven states currently have capped program enrollment for client
entry (in other words, a set limit on the number of clients capable of
being served at any one given time - typically if somebody leaves the
program, a space opens up). Ten states reported capped enrollment in
the March 1998 Interim Technical Report. The states currently
reporting capped enrollment, followed by the date the cap was
instituted (where available), are: Alabama (set 4/98), Alaska (3/98),
Florida (4/97), Georgia (1991), Idaho (4/98), Mississippi (4/97),
Montana (9/96), Nebraska (8/98), Nevada, (N/A), North Carolina (9/97)
and South Carolina (N/A). Eight of these eleven states also reported
ADAP waiting lists or capped enrollment in the March 1998 report.
Alaska, Idaho and Nebraska instituted their waiting lists in 1998,
after the release of the March 1998 interim report (Indiana and South
Dakota dropped from the list). All eleven of these states have active
waiting lists for clients to enter the program, lists that range in
size from 5 individuals in Alaska to 944 individuals in Georgia. The
total number of individuals on all eleven ADAP program waiting lists
is over 2,500. In addition to these states with current enrollment
caps, Iowa's ADAP also reported that it may need to implement a cap,
based on current projections, before the end of FY 1998.
- Six states currently have capped or restricted access to protease
inhibitors or antiretrovirals: Idaho (set 4/98), Kentucky (9/96),
Maine (N/A), Nebraska (8/98), Oklahoma (1/97), and West Virginia
(11/97); seven states reported capping PIs/other antiretrovirals in
the March 1998 report. Of these states currently reporting this
limitation, Idaho, Kentucky, Maine and Oklahoma reported that they
have active waiting lists for individuals to access PIs or
antiretrovirals - lists that range in size from eleven individuals in
Idaho to 111 individuals in Oklahoma. Four states out of the six
currently reporting PI/antiretroviral caps also reported this
limitation in the March 1998 report. Nebraska and West Virginia
instituted their caps after the March 1998 report (the District of
Columbia, Mississippi and Nevada dropped from the list).
- Five states currently have monthly or yearly per capita
expenditure caps (in other words clients may not exceed a pre-set
spending limit for reimbursement of pharmaceuticals covered in a given
month, or a given year). In Illinois the cap is $1,000 per month (set
7/98); Mississippi - $12,000 per year (4/97); Missouri - $16,000 per
year (11/96); Oklahoma - $6,000 per year (4/96); and South Dakota -
$5,000 per year (4/97).
- One state reported that it reduced its ADAP formulary: Nebraska
(8/98).
- Two states reported that they have not restored previous actions
which lowered the financial eligibility threshold for client entry
into ADAP: Idaho (set 12/97) and West Virginia (11/97). In addition,
Iowa reported that it may need to lower financial eligibility, based
on current projections, before the end of FY 1998 (possibly by January
1999).
- Four states transferred funds to ADAP from other services such as
local HIV care programs, HIV prevention or other public health
programs: Idaho (set 12/97), Iowa (3/98), Kentucky (4/98), and Maine
(9/98). In addition to these states, six additional ADAPs (Arkansas,
Nebraska, North Carolina, Puerto Rico, Texas and West Virginia)
reported that they may need to transfer funds from other services to
ADAP, based on current projections, before the end of FY 1998 (in
early 1999).
- Two states (Arkansas and South Dakota) do not currently offer
protease inhibitors on their formularies. In addition to special
program limits, 14 states reported that, based on current budget
projections, their ADAPs are expected to exhaust their current
operating budgets prior to the end of the Ryan White Fiscal Year 1998
(March 31, 1999). These states are: Arkansas, Colorado, Connecticut,
Hawaii, Iowa, Louisiana, Maine, Nebraska, North Carolina, Oklahoma,
Puerto Rico, South Dakota, Texas and West Virginia. Thirteen states
projected potential budget shortages in FY 1997. The current projected
shortages total nearly $20 million, with the largest estimated
shortages reported by Puerto Rico ($4 million) and Texas ($6.9
million). In terms of percentage of states' overall ADAP budgets, the
estimated shortages range from a low of 8% in Hawaii to 50% each in
Connecticut and in Louisiana. Taken together, roughly half the state
ADAPs (26 out of 52) have either special program limitations and/or
projected budget shortages.
Unexpended ADAP Funds Balanced
against those states with ADAP program limits and budget shortages are
those states that have reported ADAP budget surpluses in the last
year.
Eighteen states reported that they had unexpended federal funds
remaining in their budget at the end of Ryan White FY 1997 (March 31,
1998). The states were Alaska, Arkansas, Idaho, Indiana, Iowa, Maryland,
Michigan, Minnesota, Nevada, New Hampshire, New Jersey, North Dakota,
Oregon, Rhode Island, South Dakota, Tennessee, Utah and Washington. The
majority of these states (eleven out of 18) indicated that they carried
these funds over as part of the Ryan White FY 1998 ADAP budget (and
these amounts are reflected in the state-by-state budget breakdowns as
"Other Federal Funds," shown in Appendix X). Notably, Alaska, Arkansas,
Idaho, Iowa, Nevada and South Dakota are among those states that
reported one form or another of ADAP program limitation. Two of the
states that had unexpended funds at the end of FY 1997 (Alaska and
Idaho) had previously reported that they would potentially face ADAP
budget shortages prior to the end of FY 1997. However, both Alaska and
Idaho received low dollar allocations from the Ryan White CARE Act in FY
1997 (less than $400,000 each), and carried relatively small balances
into FY 1998.
Nine states reported that they anticipate their ADAP will have
unexpended funds in its operating budget at the end of Ryan White FY
1998 (March 31, 1999). These states are: Maryland, Minnesota, New
Hampshire, New Jersey, North Dakota, Oregon, Rhode Island, Utah and
Washington. These same states had reported unexpended ADAP funds for FY
1997. The estimated unexpended balances from the nine states total over
$8.6 million.
States were not asked on the survey to explain the existence of
unexpended funds. However, follow-up with several states indicates a
number of reasons why some programs have unexpended ADAP funds at the
end of the fiscal year. For example, Washington State maintained and
carried-over unexpended funds from one Ryan White fiscal year to another
as a means to manage program growth across different federal and state
fiscal years. In many states, ADAPs may not overspend and must put
limitations in place to prevent the program from doing so. This may
result in small amounts of unexpended funds that can be carried over
into the next fiscal year, even if the ADAP has an enrollment
cap/waiting list.
The presence of unexpended funds may also point to lack of access to
an ADAP, the need for more outreach to inform potential clients about
the program, or a simple lack of need for the funds. More state-specific
analysis should be conducted to draw clearer conclusions about the
reasons for unexpended funds.
Trends in ADAP Eligibility, Drug Formulary
Coverage, and Responsiveness to Evolving Clinical
Practice Clinical HIV practice continues to evolve at a
rapid rate. Changes in ADAP eligibility criteria, drug formularies and
clinical education/outreach programs often reflect state efforts to keep
pace with the changing treatment environment. This section will describe
changes in state ADAP financial and medical eligibility criteria,
formulary additions/deletions, and state efforts to disseminate and
implement federal HIV treatment guidelines.
Eligibility Criteria State ADAPs
establish both financial and medical eligibility criteria for access to
their ADAPs leading to significant variation across the programs.
Financial eligibility is usually expressed as a percentage of the
Federal Poverty Level (FPL). Most states simply follow the basic federal
statutory requirement in establishing medical eligibility for their
ADAPs-that a recipient of Ryan White care services is HIV-positive.
However a few states establish additional medical criteria for access to
their ADAPs.
Six states reported that they altered their financial eligibility
criteria since the March 1998 Interim Technical Report. Idaho and West
Virginia both lowered their financial eligibility threshold: Idaho from
400% to 200% of the FPL, West Virginia from 300% to 250% of the FPL.
Three states increased the maximum allowable income for ADAP clients:
Illinois raised its eligibility threshold from 200% to 400% of the FPL,
Oregon from 250% to 325% of FPL and Vermont, while preserving its income
threshold at 200% of FPL, switched to counting net available income
rather than gross income when making eligibility determinations.
Maryland ADAP is unique in having a threshold for minimum income in
addition to its upper limit, due to the existence of the Maryland
Pharmacy Assistance Program (MPAP) which provides pharmaceutical
benefits to all indigent Maryland residents. The Maryland ADAP's minimum
income limit has been raised slightly, from $8,750 to $9,250, to reflect
an increase in the eligibility ceiling for MPAP.
In terms of medical eligibility, Kentucky is the only state to report
a change. The minimum CD4 count requirement of 550 cells was abandoned.
Kentucky also amended viral load eligibility requirements for its
protease inhibitor program (PIP), from a minimum of 5,000 copies to any
detectable measurement. There are now only eight states with medical
eligibility criteria for entry to ADAP that go beyond confirmation of
HIV-positive status (these criteria are listed in the ADAP
Summary Table).
Looking back to the first ADAP Monitoring Project Report (data from
July 1997), there have been few changes in eligibility criteria beyond
those outlined above. Alaska had raised its eligibility bar from 200% to
300% of the FPL after July 1997 and this remains in effect. Michigan's
eligibility threshold increased from 185% to 362% during the same time
period. In addition to Kentucky's recent medical eligibility change
(detailed above), three other states - Georgia, Indiana and Michigan -
have dropped CD4 count requirements since July 1997.
ADAP Formularies Twenty-two
states added antiretroviral drugs to their formularies since July 1997.
In some cases, states added antiretrovirals that had been approved by
the FDA some time ago, e.g., the non-nucleoside reverse transcriptase
inhibitors (NNRTIs) nevirapine (Viramune), approved in June 1996 and
delavirdine (Rescriptor), approved in April 1997. Six states reported
adding nevirapine to their formularies since July 1997: Alabama,
Arkansas, Idaho, Louisiana, Pennsylvania and Tennessee. Three states -
Iowa, Maine and Puerto Rico - have yet to add nevirapine to their
formularies over two years after approval. Eight states reported the
addition of delavirdine during 1998: Alabama, Idaho, Kentucky, Maryland,
Missouri, Pennsylvania, South Dakota and Tennessee. Five states remain
without delavirdine on their formularies: Arkansas, Iowa, Maine,
Mississippi and Puerto Rico.
Two new versions of existing drugs faced few difficulties in
attaining ADAP coverage: Combivir, a combination AZT/3TC pill that is
priced as the sum of its constituent parts, and Fortovase, a better
absorbed formulation of the protease inhibitor saquinavir, priced
equivalent to the previous version, Invirase. All ADAPs are covering
Combivir. The only ADAPs not covering Fortovase brand saquinavir are
Arkansas and South Dakota, which do not cover any protease inhibitors on
their formularies.
The NNRTI antiretroviral efavirenz (Sustiva), was cleared for
marketing by the FDA on September 17, 1998. Most ADAP survey responses
were submitted before that date or shortly thereafter, so complete data
are lacking as to exactly how many programs have added this drug to
their formularies. However, 12 states reported adding efavirenz:
Arizona, Florida, Georgia, Hawaii, Kansas, Louisiana, Nevada, New
Hampshire, New Mexico, Ohio, Vermont and West Virginia. As discussed
earlier in this report, several states, including New York and
California, decided to delay coverage of efavirenz due to its higher
cost compared to other drugs in the NNRTI class.
At the time of the first ADAP Monitoring
Project Report (July 1997 data), only two states-New York and North
Carolina-reported covering all FDA-approved antiretrovirals. At the time
of the production of this report the situation has improved
dramatically, with 46 state ADAPs offering all 12 FDA-approved
antiretroviral drugs. Abacavir (Ziagen), the thirteenth antiretroviral
to receive FDA-approval, was approved after the survey completion
deadline and is therefore not included in this analysis.
Thirteen states reported adding hydroxyurea, a longstanding cancer
chemotherapy, to their formularies, bringing the total number of states
covering this drug to 15. Hydroxyurea is not yet indicated for the
treatment of HIV infection, but recent studies suggest it has a useful
role to play. The fact that the drug is off-patent and inexpensive may
also be a point in its favor from the perspective of ADAPs.
Twenty-three states added drugs for the prevention and treatment of
opportunistic infections and other non-antiretroviral drugs to their
formularies since July 1997. The most dramatic changes in OI/other drug
coverage occurred in California and Oregon, where the ADAP formularies
were greatly expanded. California added more than fifty drugs, including
psychotropics and anabolic steroids. Oregon underwent a massive
formulary expansion by increasing the number of OI-related treatments
from seven to 180, approaching an "open" formulary model. This expansion
was made possible by shifting eligible ADAP clients into an
insurance-purchasing program, thereby reducing ADAP expenditures for
these individuals. Oregon also became the first ADAP to include
lipid-lowering agents on its formulary. Protease inhibitor-related
hyperlipidemia has been an increasingly reported problem, and recent
studies suggest that lipid-lowering agents may successfully control this
side effect in some patients.
Other states have made relatively minor changes in their OI-related
drug coverage. New York, like California, made its first foray in the
coverage of anabolic steroids for the treatment of weight loss. Four
states (Delaware, North Carolina, Ohio, South Carolina) added
antimycobacterial drugs that they had not previously offered. Washington
State, experiencing less utilization than previously predicted, was able
to begin offering antidepressant medications. Overall, 21 states now
cover ten or more of the 14 drugs strongly recommended in the USPHS/IDSA
"Guidelines for the Prevention of Opportunistic Infections for Persons
Infected with HIV," up from 19 since December 1996.
The only major deletion of formulary drugs occurred in Nebraska due
to a rapid increase in utilization and the resulting fiscal crisis. All
17 non-antiretroviral drugs were removed from Nebraska's ADAP formulary
in August of 1998 as a result of a severe budget shortfall.
An updated ADAP formulary chart that lists all drugs covered by each
state is included in Appendix XIV, with new drugs added since July 1997
indicated in bold. Drugs that were added between the first Monitoring
Project Report survey period (December 1996) and July 1997 are
highlighted in italics.
Federal HIV Treatment Guidelines
Dissemination In April 1998, the federal government
released its "Guidelines for the Use of Antiretroviral Agents on
HIV-infected Adults and Adolescents." The March 1998 Interim Technical
Report reported on state efforts to disseminate these guidelines to
providers and, in some cases, consumers, while the Guidelines were in
final draft form. The Guidelines are recognized as a definitive source
of information on the standard of care for HIV-infected individuals and
will be updated periodically to keep pace with advances in HIV
therapeutics and clinical practice. When states were asked to report on
HIV/AIDS program efforts (since March 1998) to disseminate the
Guidelines to their provider and consumer communities, a number of
common strategies emerged:
Mailings Arguably one of the
most straightforward methods of dissemination, 17 states reported
mailing guidelines to ADAP clinicians and/or providers. In response to a
separate survey question, 41 states were able to provide data on the
number of medical providers prescribing for ADAP clients, suggesting
that mailings could be targeted with a fair degree of accuracy.
Drug Utilization Review (DUR) In
the past few years, an increasing number of states have adopted
computerized systems that allow detailed analysis of physician
prescribing and pharmacy medication dispensing. In the context of the
Guidelines, these systems can potentially be used to periodically review
clients' antiretroviral regimens. Nine states reported using some type
of DUR to monitor for compliance with the PHS Guidelines. California,
Maryland, Pennsylvania and South Carolina all cite ongoing use of DUR
with the potential for follow-up with the prescriber and/or client when
combinations are notably divergent from those recommended.
Massachusetts, Michigan, and New Jersey reported ongoing studies of DUR.
These studies will be analyzed to provide an overview of how prescribing
patterns of ADAP physicians compare to the PHS Guidelines. New York ADAP
already conducts such analyses periodically. Maine is in the early
stages of developing computerized utilization review in conjunction with
the state Medicaid program.
AIDS Education and Training Centers
(AETCs) Twelve states specifically mentioned collaboration
with their AETCs to facilitate Guidelines dissemination. The AETCs
provide Continuing Medical Education (CME)-accredited training to
providers, either on site or through conferences.
Consumer Education Twelve states
provided information on education initiatives for ADAP consumers.
Treatment and adherence education and/or support are the main focus of
these efforts. A brief summary of the states and their survey responses
is included in Table A:
Table A Examples of State ADAP
Consumer Education Initiatives
State |
Type of
Consumer Education |
Alaska |
Statewide team of providers
and consumers attended Adherence Conference. |
Colorado |
Four adherence enhancement
programs funded by the state. |
Florida |
A treatment adherence and
patient education subcommittee of the ADAP workgroup was recently
formed and is developing adherence guidelines for distribution to
both the public and private sector. |
Maryland |
In June 1998, MADAP mailed
to all enrolled clients an adherence kit containing educational
materials describing the importance of adherence to antiretroviral
therapies, a medication organizer and other supporting materials.
MADAP monitors the prescription utilization of clients, and those
that do not appear consistent with PHS guidelines are targeted for
follow-up consumer education, if appropriate. |
Massachusetts |
The HIV/AIDS Bureau
continues to fund a consumer-led treatment education program that
is statewide. |
Missouri |
The state developed client
surveys and educational brochures regarding treatment and
adherence and piloted two client health programs in the St. Louis
area. |
New Hampshire |
AETC presented updates from
the 12th International AIDS Conference in Geneva for consumers and
providers. |
New York |
Consumer programs include a
Treatment Education Initiative, which targets consumers from
hard-to-reach groups and the staff of community based
organizations. The Initiative also funds organizations to develop
model programs that assist patient adherence. |
Pennsylvania |
The state ADAP contracted
with the Pennsylvania AETC to provide client/provider programs
regarding clinical developments and adherence issues. This
includes an ongoing initiative with the AETC to develop a consumer
survey to collect data on consumer knowledge about antiretrovirals
and adherence. |
South Carolina |
The state provides
medication dosage organizers, if needed. |
Washington |
The state produced two
adherence videos in conjunction with the AETC and held a statewide
conference for consumers and care providers with 320
attendees. |
Wisconsin |
The state has planned and
implemented educational initiatives for both consumers and care
providers since August 1997, including the PLWHIV Conference, the
annual statewide AIDS/HIV Conference and distribution of the
quarterly AIDS Update. |
Care Consortia Care consortia
are funded through Title II of the Ryan White CARE Act. The consortia
are charged by the Act to assess the needs of all populations with HIV
disease in the state, develop a plan for meeting identified needs
through a continuum of outpatient medical and support services, promote
the coordination of community resources, assure continuity of services
through effective case management, and periodically evaluate their own
effectiveness in responding to service needs and providing
cost-effective alternatives to hospitalization. Eight states
specifically reported utilizing regional consortia to assist in
disseminating the PHS
Guidelines.
Conferences, Videos and Other
Initiatives Fourteen states have co-sponsored HIV/AIDS
conferences that included sessions on the PHS Guidelines. Alaska and
Florida both reported regular use of video/teleconferences. South Dakota
has taped copies of the PHS Guidelines Video Conference available for
viewing free-of-charge. One state, Washington, reported creating its own
Guidelines video, which was produced in collaboration with their
AETC.
Novel mechanisms for assisting with Guidelines dissemination were
cited by two states. Florida ADAP, in collaboration with its Medicaid
program, offers computerized CD-ROM treatment protocols. Louisiana
collaborated with the Pediatric AIDS Program at a local Children's
Hospital to develop a physician's "Lab Coat Protocol Card." The card
includes the Internet address for the PHS Guidelines and the toll-free
number for the HIV Telephone Consultation Service at San Francisco
General Hospital.
Conclusions ADAP Monitoring
Project data have been collected since July 1996, allowing this report
to view the evolution of the programs through time. The picture is one
of continuous growth, both in terms of clients served and escalating
expenditures. It is also a picture of continuing variation among ADAPs.
The heterogeneity of state ADAPs permits few other broad conclusions to
be drawn. Based on the findings of this report and the previous
Monitoring Project reports, there are several significant challenges
that ADAPs face as they move into 1999:
- Inequalities in ADAP Funding:
The current report documents
growing disparities between the states, as some programs experience an
apparent peak in demand while others continue to document rapid
growth, particularly in costs. The current report finds that while
eleven ADAPs have waiting lists, nine others have unexpended funds to
carry forward into FY 1999. The upcoming reauthorization of the Ryan
White CARE Act may provide an opportunity to re-examine these issues.
However, given the politically charged funding environment, replete
with often fractious debate over state and federal responsibilities,
an easy resolution to these problems appears elusive.
- Racial/Ethnic Disparities in the Utilization of ADAP
Services:
A critical issue addressed in this report is the
representation of different demographic groups within the current ADAP
client population. However, data presented here should be viewed
within the context of other available data sources nationally and
within each state to arrive at a truly accurate assessment of whether
actual disparities in treatment access exist. Still, ADAPs are being
called to greater accountability for their efforts to reach and serve
traditionally underserved populations. Trying to confront the
cultural, financial, political and systemic factors that result in
unequal access to care-and specifically access to HIV treatments-is
not an easy task. Ongoing efforts should be made to ensure that the
potential existing disparities are not simply perpetuated by ADAP or
any other HIV service system. The ADAP Monitoring Project will
continue to review client demographics in future reports.
- The Impact of Medicaid Coverage on ADAPs:
It is clear that
the policies of state Medicaid programs are critical in determining
the demand for, and adequacy of, state ADAP services. This fact is
highlighted in the analysis of Medicaid policies and ADAP status in
the March 1998 Interim Technical Report, and further supported by the
information on the income levels of state ADAP clients documented in
this report. The problem of limited Medicaid benefits and restrictive
eligibility is particularly evident in the southeastern US. The states
with the largest ADAP waiting lists at the time of this report are
Alabama, Florida, Georgia, North Carolina and South Carolina-all
states with limited or less expansive Medicaid coverage.
- Availability of Cost-Savings Options:
In late 1998, the
Public Health Service 340B drug discount program was modified to
include a rebate option so that all state ADAPs could take advantage
of the savings offered under this program. States are also looking at
other innovative options to reduce the cost of providing HIV
treatments and care to lower income clients who lack adequate
insurance. As documented by these reports, the use of insurance
purchasing/continuation programs is significant among these options.
However, the availability of comprehensive high-risk pool insurance
coverage varies greatly from state-to-state. Minnesota has experienced
no fiscal ADAP problems, in large part due to the cost-effective
purchase of high-risk insurance for eligible ADAP clients. Oregon's
ADAP, which historically offered a relatively meager array of
HIV-related drugs, underwent a massive formulary expansion after
reducing their client load by purchasing high-risk insurance for
eligible individuals. Several other ADAPs are now moving in this
direction. Others, however, may be limited in their ability to pursue
this cost-effective option if their state has no high-risk insurance
pool and/or has unfavorable insurance law, regulations or practice.
- Combination Therapy and Increasing HIV/AIDS Drug Prices:
The evolution of the standard of care for HIV/AIDS is the major factor
driving the rapid increase in ADAP expenditures. The transition from
single-drug HIV therapy to the wide utilization of multi-drug highly
active antiretroviral therapy (HAART) combinations has taken place
over the period of these reports. The ever-rising prices of HIV
therapies are also a significant burden upon ADAP programs,
necessitating renewed efforts to control drug costs. Several companies
instituted price increases during 1998 at rates that exceeded the
consumer price index. Additionally several new antiretroviral drugs
are due to be approved in 1999, and an apparent trend toward higher
prices should be addressed if another fiscal crisis year for ADAPs is
to be avoided. The institution of the 340B ADAP rebate option and some
degree of collective bargaining by ADAPs, as outlined in this report,
are promising strategies that should be strengthened and maintained.
- Development of New Classes of Therapy:
Attempting to
predict the future of HIV treatment is often a foolhardy exercise, but
two nascent areas of research are worthy of attention. The advent of
immune-based therapies, including therapeutic vaccinations, could
represent a significant add-on cost for ADAPs if these therapies are
used only as an adjunct to HAART. But some researchers are suggesting
that such therapies might permit long-term immunologic control of HIV
replication without antiretroviral drug therapy. Eagerly awaited data
from ongoing studies of immune-based interventions may better inform
cost predictions and further improve care for people living with
HIV/AIDS in the next couple of years.
- Prudent Use of Available Funds:
ADAP budgets-and
specifically the federal ADAP supplemental-have generally increased
significantly over the past two years; however Title II base funding,
which provides support for primary care, case management and other
supportive services in addition to ADAP, has been relatively stagnant.
Is it prudent for states that rely solely on Title II dollars to
provide AIDS care to spend a significant portion of their base Title
II money for ADAP services? How can states with large amounts of
unexpended ADAP funds utilize these dollars to the benefit of
potentially eligible clients? By expanding their drug formulary? By
increasing outreach activities? Due to the heterogeneity of ADAPs,
these types of questions can only be answered in light of the specific
political, social and economic circumstances of each state.
Absent a constructive resolution to these challenges, it is
difficult to envision how truly consistent, comprehensive and
accessible healthcare services might be made available to indigent,
uninsured and underinsured individuals with HIV infection nationwide.
The expansion of Medicaid coverage to non-disabled individuals with
HIV seems unlikely to be directed from the national level. Perhaps
state demonstration programs will be able to determine the
cost-effectiveness of such an approach. In the meantime, ADAPs will
continue to be part-a critical part-of a patchwork quilt of services,
highly susceptible to unraveling at the slightest political tug. As
the number of Americans without health insurance grows, it is likely
that ADAPs will be stretched to cover increasing numbers of uninsured,
lower income people living with
HIV/AIDS. |