United Press International - May 19, 2004
Ellen Beck, United Press International

It is not an issue of failing to support the domestic program. For the past two years, the administration has boosted federal funding for state-run AIDS Drug Assistance Programs -- from $693 million in fiscal year 2003 to $728 million in FY 2004.

Part of problem is HIV/AIDS patients are now living longer, thanks to multi-drug, anti-retroviral drug cocktails, so they continue on the medications and in the ADAP program longer. This fact, combined with significant increases in the cost of these drugs and the fact that, other than federal monies, ADAP funding sources are, at best, volatile, creates a growing financial squeeze.

Last weekend, Health and Human Services Secretary Tommy Thompson proposed an expedited review process, through which the United States will approve low-cost HIV/AIDS drugs it sends to developing countries as part of President Bush's $15 billion Emergency Plan for AIDS Relief.

The approval process has been a bone of contention among HIV/AIDS activists. Many have criticized it as creating a laborious, unnecessary and extra U.S. approval tier when existing international standards could evaluate the drugs effectively and get them to needy countries more quickly. Nevertheless, the World Health Organization welcomed the new HHS initiative.

The additional international AIDS money, however, comes at a time when state ADAP programs struggling with limited funding are closing enrollment. They also are limiting drug formularies and setting up waiting lists. This is according to the eighth annual National ADAP Monitoring Report conducted by the Kaiser Family Foundation, with the help of ADAP programs and other federal healthcare agencies.

Jennifer Kates, director for HIV policy at Kaiser, told a news briefing Wednesday that state ADAP programs serve "a relatively significant number of low-income people each year -- 136,000 people -- or 30 percent of the HIV/AIDS patients in the United States who are getting medical care for the disease.

"They've grown in importance over time as more people are living with HIV/AIDS, as costs have increased," she said. "What people are able to get completely depends on where they live."

Aside from federal funding, the ADAP programs -- established in 1987 to help provide prescription medicines for HIV-infected patients who did not have private insurance and were ineligible for Medicaid -- cobble together a mishmash of other state and public funding sources to survive.

These grants and programs, however, are not entitlements, so they cannot be counted on from year to year. Programs tied to state budgets are especially unpredictable, because most state Legislatures have faced a revenue crisis over the past several years and have been forced to implement deep spending cuts to balance the books.

Financial shortfalls have been a growing problem for ADAPs since the mid-1990s, coinciding roughly with the arrival of the anti-retrovirals -- HIV, the organism that causes AIDS, is a retrovirus.

The report, which looked at a snapshot of the situation in June 2003, found at that time 11 states had closed ADAP enrollment to new clients. Nine had a total 1,263 people on waiting lists, two had reduced the number of drugs offered, three had imposed monthly expenditure caps and one increased co-pays for users.

For that month, however, ADAPs nationwide filled more than 300,000 HIV/AIDS prescriptions for clients. The so-called miracle drugs -- anti-retrovirals have turned an HIV diagnosis into a chronic illness rather than a terminal one -- eat up 86 percent of the budget. The average anti-retroviral prescription costs $357, compared to $94 for drugs that treat HIV/AIDS side effects, such as opportunist infections.

In five states, the report said, the increase in federal monies for ADAP programs was not enough to balance the loss of funding from other sources. The net result was an overall reduction in available monies for the year.

Ron Weinstein, ADAP coordinator in New Jersey, told the briefing: "This year is going to be a challenge in New Jersey. The current level of services is not sustainable without tapping into new revenue sources."

New Jersey is one of only four state ADAP programs with an open formulary -- covering any approved drug. It also has the highest income level for eligibility -- 500 percent of the federal poverty level.

Weinstein said the program for now is focused on the "revenue side" and looking at other funding sources but has a contingency plan of cuts ready, just in case.

In Kentucky, however, it is a different picture. State AIDS Director Lisa Daniel said a waiting list has been imposed on the ADAP program since 2000 and the state covers 52 drugs -- including most of the anti-retrovirals.

She said, however, it is a "challenge" to help patients on the waiting list get the medications they need until they can get into the program.

The situation is likely to remain difficult. The number of poverty-level, HIV/AIDS sufferers in sub-Saharan Africa and other developing countries far surpasses cases in the United States.

As the Bush administration answers the global cry for additional U.S. assistance, it likely will ask the states -- even as they are challenged significantly to fund other public health programs, such as Medicaid -- to shoulder more of the financial burden of keeping ADAP programs running. It may be the only way to keep the same medications the federal government buys and sends overseas to be purchased and delivered to poor HIV/AIDS patients at home.

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Ellen Beck is UPI's Healthcare Policy Editor. E-mail sciencemail@upi.com
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