NATIONAL ADAP MONITORING PROJECT - AIDS United

Serving almost 77,000 largely uninsured and low-income
people with HIV/AIDS in June 2001, state and territorial
ADAPs continue to play a critical role in the provision of
medications to those who are uninsured and
underinsured. ADAPs fill the gaps in prescription drug
coverage and often serve as a bridge to comprehensive
health care resources including other Ryan White-funded
programs, Medicaid, and private insurance. After a
major shock to the system in late 1995—with the
introduction of protease inhibitors and combination
therapy as the standard of care—trends in ADAP client,
expenditure, and budget growth have remained relatively
constant, as all three continue to grow but at slower rates.
National ADAP budget growth, however, has not
eliminated program restrictions and limitations in some
states, and some states have experienced large
fluctuations in client utilization, expenditures, and
budgets over time. In addition, as discretionary
programs that rely mainly on annual federal—and in
some cases, state—appropriations, ADAPs’ continuing
fiscal stability is subject to changes in federal and state
political, economic, and social priorities. ADAPs often
cannot predict whether they will face budget shortfalls
until well into their fiscal year.
While these overall trends are expected to continue,
there are several factors and issues on the horizon that
could affect the ability of ADAPs to meet increasing
client demand over time. These factors include:
The Fiscal Outlook
• The Office of Management and Budget (OMB) is
predicting a federal deficit that will reach over $106
billion in FY 2002 and over $80 billion in FY 2003. 1,2
This economic downturn has had a dramatic impact
on states. The National Association of State Budget
Officers (NASBO) and the National Governors
Association (NGA) report that total state deficits
reached $40 billion in FY 2001. 3 Statutes in many
states prohibit deficit spending, forcing these states to
enact drastic budget cuts. At the same time, the costs
involved in strengthening the public health system’s
bioterrorism preparedness have become the focus of
attention. Budget deficits and a focus on
bioterrorism at both the federal and state level have
already resulted in resource constraints.
Conclusion
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• For the second year, President Bush has
recommended flat funding for certain federal
HIV/AIDS programs in his FY 2003 proposed
budget, including the ADAP program. Last year,
ADAP programs fared well during Congressional
appropriations. Final appropriations for FY 2003 are
not yet known. With federal dollars accounting for
the core of the national ADAP budget, some states
could be forced to further restrict access to ADAP
programs.
• The continuing increases in the price of medications
coincide with federal and state fiscal concerns. The
price of prescription drugs increased more than three
times the rate of inflation between 1998 and 2000. 4
While the federal drug discount program (the 340B
Program) used by most ADAPs largely shields them
from annual price increases greater than inflation, a
drug company that has not increased prices for two or
more quarters may include past inflationary increases
in a single quarter increase. 5 This recently occurred
in the case of Sustiva, a popular non-nucleoside
reverse transcriptase inhibitor (NNRTI) used in many
protease-sparing regimens, whose price to ADAPs
rose by 10%. 6 Such a sudden increase makes it more
difficult for ADAPs to budget effectively.
The Treatment/Technological
Outlook
• T-20, the first fusion inhibitor, could receive FDA
approval prior to the end of 2002, marking the first
dramatic technological change in HIV treatment since
the introduction of protease inhibitors. 7 Initial data on
this drug indicate that it is highly effective, particularly
when treating patients who have developed multiple
drug resistance to the current drug classes. Beyond
2002, other fusion inhibitors besides T-20 will likely
receive approval, in addition to another new class of
drugs, integrase inhibitors, and new generations of
existing classes, creating further shifts in highly active
antiretroviral therapy (HAART). 8 The impact of these
changes on ADAP client utilization and drug
expenditures remains unclear.
• Structured intermittent therapy (SIT), consisting of
defined periods on and then off treatment designed to
ease the effects of HAART and potentially increase