Friday, March 31, 2000 PUBLIC HEALTH & EDUCATION ADAPS: See Increase in Clients, Expenditures       While federal contributions to AIDS Drug Assistance Programs have increased, "ADAPs continue to face the challenge of meeting the needs of an increasing client base and high drug costs in an era of rapidly changing treatment standards," according to the "National ADAP Monitoring Project Annual Report" released this week by the Kaiser Family Foundation. ADAPs, administered by states, provide HIV/AIDS- related prescription drugs to low-income, uninsured and underinsured individuals living with HIV/AIDS in the 50 states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands (Kaiser Family Foundation release, 3/24). The report analyzed the fiscal, administrative and programmatic status of ADAPs by comparing June 1999 figures to those of the previous year and to data gathered since the inception of the national ADAP monitoring project in 1996, finding that ADAP programs and access to ADAPs varied greatly across states. While ADAPs continue to receive an increasing amount of federal funds through the Ryan White CARE Act and other sources, the introduction of combination antiretroviral therapy has contributed to rising expenses and increasing numbers of ADAP clients, sometimes leading to ADAP budget shortfalls and program restrictions. In FY 1999, the total ADAP budget from all federal and state sources was $665.5 million -- a 30% increase over the FY 1998 budget (ADAP annual report, March 2000). Kaiser Family Foundation President Drew Altman explained: "In most states, ADAP programs have been able to fill the gaps in access to prescription drugs for the nation's low-income, HIV-infected population. Federal contributions to ADAPs have been growing but as treatment standards continue to call for newer, more expensive drugs in combination, these programs will continue to be challenged to meet the needs of their clients" (Kaiser Family Foundation release, 3/24). Clients Served       From July 1996 to June 1999, the number of clients served by ADAPs doubled, from 24,472 to 54,981. From June 1998 to June 1999 alone, ADAPs experienced a 16% increase in the number of clients served. States that have been hardest hit by HIV/AIDS, such as Florida, New York, California and Texas, have contributed the most to the increasing number of clients and expenditures. In addition, researchers found "little change" in the demographics of ADAP clients between June 1998 and June 1999; most clients were low-income, uninsured and represented a "mix of racial and ethnic population groups" (ADAP Annual Report, March 2000). In June 1999, 80% of ADAP clients had incomes at or below 200% of the federal poverty limit, 7% qualified for Medicaid and 7% had private health insurance with some level of prescription drug coverage. Forty percent of ADAP clients in June 1999 were white, nearly one-third were African American and one-quarter were Hispanic. Kaiser Family Foundation Vice President Marsha Lillie-Blanton said, "As the HIV epidemic shifts further into traditionally underserved populations, particularly rural and ethnic minority populations and women, state ADAP programs will be increasingly challenged to improve access and provide treatments to these populations, through innovative outreach and education initiatives" (KFF release, 3/24). Budgetary Woes       In June 1999, ADAP expenditures totaled $46,778,490. Nationwide, per client expenditures increased 6% from June 1998 to June 1999. And between 1996 and 1999, monthly program expenditures more than tripled, climbing from $13.3 million in July 1996 to $43.1 million in June 1999. Ten states reported expenditure increases of 50% or more; only six ADAPs reported decreases in expenditures. The price for antiretroviral drugs and drugs used to ward off opportunistic infections are in part responsible for the increased costs. Antiretrovirals are the "main driver of overall program expenditure increases" and represent almost 90% of all program expenses, increasing by 25% from June 1998 to June 1999. During the same time period, drug costs for opportunistic infections and for non-antiretroviral drugs increased by 21%. Program Variations       Financial eligibility criteria vary widely from state to state, with Georgia and North Carolina having the most restrictive criteria, at 125% of the federal poverty level, and New York the least restrictive, at 500% of the federal poverty level. The ADAP formularies also vary by state, ranging from fewer than 20 drugs covered in Alaska, Colorado, Georgia, Louisiana and Nebraska to more than 100 drugs in California, New York, Oregon and Puerto Rico. Only 23 states cover 10 or more of the 16 drugs recommended for the prevention of opportunistic infections. These variations are in part the result of the availability of resources and state discretion over ADAP eligibility criteria and drug formulary coverage. Although increased federal funding has helped many ADAPs meet increased client demand, several ADAPs with tight budgets have reported access limitations. Eleven ADAPs reported capped enrollment, while nine others reported other limitations. Six ADAPs have either capped or restricted access to antiretroviral drugs and one ADAP does not cover any protease inhibitors. Further, nine states expect to fully exhaust their current budget before the end of FY 1999. Six states reported they expect to have unanticipated funds remaining in their budget at the end of FY 1999, which is a drop from the 16 states that reported the same last year (ADAP annual report, March 2000). "The influx of additional ADAP funding alone may not fully ameliorate ADAP limitation in these states since they are likely related to policy choices states have made about Medicaid eligibility and funding for state ADAPs," Arnold Doyle, director of HIV Treatment Programs for the National Alliance of State and Territorial AIDS Directors, said (Kaiser Family Foundation release, 3/24). Still, some ADAPs have been able to expand their programs. Seven states have increased their income eligibility threshold and two have eliminated medical eligibility treatment criteria based on CD4 cell counts or viral load measurements. Currently, only five states rely on medical eligibility requirements beyond the basic requirement of documented HIV infection. Forty-five ADAPs cover all approved antiretroviral treatments and 23 states have added drugs for preventing and treating opportunistic infections and other non-antiretroviral drugs (ADAP Annual Report, March 2000). The report is the fourth in a series commissioned by the Kaiser Family Foundation and was prepared by the National Alliance of State and Territorial AIDS Directors and the AIDS Treatment Data Network (Kaiser Family Foundation release, 3/24). Kaiser Daily HIV/AIDS Report