States Slashing H.I.V. Drug Programs Amid Budget Deficits

By: David Ostrowsky

Over one million Americans live with H.I.V. and  nearly 25 percent of them rely on the Ryan White AIDS Drug Assistance Programs, otherwise known as ADAPs, to manage their conditions. These federally-funded assistance programs are a life-saver for low-income, uninsured and underinsured Americans suffering from H.I.V. as they provide subsidized or even free specialty medications that suppress the virus to undetectable levels, thus eliminating its potential spread. And yet, according to a report from the National Alliance of State and Territorial AIDS Directors (NASTAD), nearly twenty states—ones with both Democratic and Republican leadership—have recently imposed new restrictions on ADAPs such as limiting eligibility by income and scope of services, or reducing their drug formularies, while another handful of states are contemplating making similar changes as well as implementing waitlists.

All of which begs some pressing questions—a.) Why now? and b.) Which states are most affected?

A Decade in the Making

According to a recent report from the Kaiser Family Foundation (KFF), over a decade of stagnant appropriations from Congress—established at $900.3 million since fiscal year 2014—have essentially led to ADAPs having the same purchasing power as they did in 1999 due to inflation. The subsequent shortfall in federal fiscal support has translated to states receiving lower grants that are not keeping pace with demand and costs of this program as well as rising insurance premiums. For just one example of how popular ADAPs have become, new enrollments for state H.I.V. assistance programs spiked 30% from 2022 to 2024, a development partially attributable to states cutting off pandemic-era Medicaid assistance. In other words, H.I.V. patients who no longer qualified for Medicaid turned to state ADAPs to pay for their medication, insurance, or, in some cases, both. The end result is that nearly half of America, including Washington, D.C., feels inclined to roll out cost-cutting measures, most notably restricting eligibility to very poor residents and ceasing coverage for many medications.

The States Most Affected

In the first week of March, thousands of Floridians suffering from H.I.V. learned that they were no longer eligible for ADAPs. The Florida Department of Health, positing that program changes were necessary to prevent a budget gap of more than $120 million, issued emergency rules that ADAP funds will only be accessible for people at or below 130% of the federal poverty line—a precipitous decline from 400%. (This is the approximate equivalent of dropping from $63,840 to $20,748 annually.) Furthermore, the emergency rules have also restricted the insurance coverage of Biktarvy, a once-a-day pill that is used by 60% of the 30,000 Floridians enrolled in ADAP and is one of the most widely prescribed H.I.V. treatment medications in the US. However, a couple weeks later the Florida House of Representatives passed bill HB 697, which includes a stopgap measure to restore ADAP cuts through June 30, the end of the fiscal year. The bill, which is headed to Governor Ron DeSantis’ desk, includes $31 million to restore eligibility to over 11,000 people until the legislature passes a budget.

Meanwhile, per the National Alliance of State and Territorial AIDS Directors, ADAPs in Pennsylvania, Kansas, Delaware, and Rhode Island have altered income eligibility limits, and changes implemented by other states have included lowering funding for medical services, implementing twice-a-year eligibility checks, and adopting annual or monthly spending caps per enrollee. However, to date, no states have imposed waiting lists—a widely used tactic in the early 2000s when there was an excessive number of H.I.V. patients turning to ADAPs that were underfunded.

The Potential for a Nationwide Problem

Medical experts have expressed concern that cuts to H.I.V. medications could subject more Americans to contracting the disease. Yes, the number of H.I.V. cases is well below soaring levels attained in the 1990s, but tens of thousands of U.S. residents continue to be diagnosed with H.I.V. every year, according to stats from the Centers for Disease Control and Prevention. H.I.V. patients who are taking antiretroviral medications generally maintain their health, and, as previously noted, shifting viral loads to undetectable levels also protects sexual partners from infection. But that dynamic can quickly change when patients are no longer consuming their H.I.V. medication.

“If viral load goes up because they don’t have their meds, or they have inconsistent access, they could be transmitting H.I.V. to a partner,” said Jennifer Kates, senior vice president and director of the Global and Public Health Policy Program at KFF.

And then there’s the not-so-small financial impact of a swelling number of newly infected Americans: With the lifetime cost of treating H.I.V. patients hovering around $1 million, researchers project the ADAP eligibility cuts could saddle healthcare systems with billions of dollars in added expenses.