Despite an 85% spending increase on the nation’s 52 AIDS Drug Assistance Programs (ADAPs) between 1996 and 1997, many states are unable to meet the soaring demand for the new, highly effective, but very costly, protease inhibitors.
According to a study conducted for the Kaiser Family Foundation by the
National Alliance of State and Territorial AIDS Directors (NASTAD) and the AIDS Treatment Data Network, thirty-five states took at least one emergency measure in the past year in response to the crisis.
The emergency steps included:
• capping program enrollment;
• restricting access to certain formulary medications;
• reducing drug coverage; and
• delaying or indefinitely suspending coverage of the new drugs.
About 80,000 people were served by ADAPs in 1996, but the number who are eligible for the program is two to three times that number. Available data suggests between 140,000 and 280,000 are eligible for the program.
"While there has been a significant increase in both federal and state support to ADAP in the last year, states are spending their funds almost as soon as they receive them due to growing client demand and the costly new standard of treatment, said NASTAD Deputy Director Joseph Kelly. "In many states this translates into restricted access to AIDS drugs."
Although the majority of ADAP clients are below 200% of the federal poverty level, income eligibility cutoffs range from 100% to 400% of poverty level.
The 1997 budget for the state-administered program is $385 million. The majority of funds come from federal sources. About two-thirds of total state contributions are from four states, California, Louisiana, New York, and Illinois, although thirty other states contribute.
Despite the emergency steps many states have taken, 11 states predicted a shortfall in funding for the program this year: Alabama, Arizona, Arkansas, Colorado, Montana, New Mexico, Puerto Rico, Texas, Vermont, Washington State and West Virginia.
Three other states, Florida, Mississippi and South Dakota, have been forced to severely limit services this year in response to increased demand and costs.
New federal guidelines for HIV antiretroviral therapy recommend that patients start on a combination regimen earlier in the course of HIV disease. "Unfortunately", the report notes, "many state ADAPs are unprepared to offer this standard of care to eligible patients who may be candidates for triple combination therapy." Estimated cost of therapy with a protease inhibitor, ranges from $10,000 to $15,000 a year.
One hopeful sign is that "many states are exploring innovative strategies for broadening access to HIV/AIDS therapies such as health insurance continuity programs and purchasing insurance through state risk pools," the report notes.
"There will likely be increased pressure to assure that ADAP represents the payer of last resort and that Medicaid programs are not inappropriately limiting prescription drug coverage," the report says.
"Limitations on Medicaid drug coverage applies increased pressure on financially strained ADAPs to pick up the burden of paying for drugs for underinsured Medicaid eligible populations."
There is wide variation among ADAPs in their drug coverage:
• In 1997, four state ADAPs do not cover protease inhibitors and two ADAPs cover only one protease inhibitor.
• Only five ADAPs cover the 13 basic drugs recommended by the Infectious Disease Society of America (IDSA) and Public Health Service (PHS) in 1995 for preventing opportunistic infections. Only two cover the 14 drugs recommended in the 1997 guidelines. Five ADAPs do not cover any of the recommended prophylactic drugs in the 1997 guidelines.
Finally, the report notes that many ADAPs could be squeezing more savings out of existing mechanisms like federal drug discount pricing and rebates by improving drug distribution systems
Even with these strategies, however, the Kaiser study concludes that "significant additional federal and state resources will be needed to enable ADAPs to maintain pace with demand to deliver the standard of care for HIV therapy."
To obtain a copy of the report, call NASTAD at 202-434-8090 or Kaiser Family Foundation at 800-656-4533. It can be downloaded from the Internet at http://www.aidsnyc.org/adap/.
New study says AIDS programs still cant meet demand for drugs
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