Meeting the Need: Ensuring Access to Essential Medicines for People Living with HIV/AIDS
Section 2.
In CY2022, among the 51 jurisdictions responding, 235,615 clients were served by ADAPs, representing 20% of the nearly 1.1 million people aged 13 years or older with diagnosed HIV in the United States at the end of 2021. Approximately 44% were served by ADAPs’ full-pay medication programs only,[1] 44% were served by the ADAP-funded insurance program only,[2] and 12% were served by both the ADAP-funded insurance program and the full-pay medication program.[3]
ADAP Clients Served, by Program Type, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
ADAP Clients Served and Top Ten States, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
To fulfill their mission and purpose in supporting equitable access to treatment and optimal health outcomes, ADAPs must develop and maintain systems that are responsive to the structural challenges faced by their clients. As stipulated by the Ryan White CARE Act, individuals served by RWHAP and ADAP are low-income and under/uninsured. Among all ADAP clients served during CY2022 in a responding jurisdiction, 40% had incomes at or below 100% of the federal poverty level (FPL). The majority (64%) of ADAP clients served in CY2022 had incomes at or below 200% FPL.
Less than half (43%) of ADAP clients served in CY2022 were Black, brown, indigenous, or other people of color, with most clients of color reported as Black/African American. For a five-year comparison, the proportion of Black/African American ADAP clients served in CY2022 (38%) is somewhat lower than the proportion reported in CY2017 (40%). The proportion of ADAP clients who are white has increased, from 49% in CY2017 to 54% in CY2022.
By ethnicity, 31% of ADAP clients served in CY2022 were reported as Hispanic/Latinx, compared with 28% of ADAP clients served in CY2017.[4]
The majority of ADAP clients served in CY2022 identified as male (78%) whereas 20% identified as female and 1% as transgender. Comparatively, 49% and 51% of the U.S. population in 2022 were reported as male and female, respectively. This difference is reflective of the disproportionate prevalence of HIV among men nationally; 76% of all adult and adolescent PLWHA in 2021 were male.
Effective antiretroviral regimens have enabled many PLWHA, including ADAP clients, to achieve a near-normal life expectancy and experience fewer AIDS-related conditions (e.g., opportunistic infections). As a result, the proportion of ADAP clients who are older – and consequently facing an increased risk of non-AIDS-related health complications (e.g., cardiovascular disease and cancer) and/or potentially requiring wrap-around support for outpatient medications covered under Medicare Part B or D – has and will continue to grow. In CY2022, the majority (57%) of ADAP clients served were 45 years or older; 13% were 65 years or older. Comparatively, in CY2017, while the same percentage of clients were 45 years and older, 8% were 65 years or older.
ADAP Clients Served, by Demographic, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data. Percentages may not total 100% due to rounding.
To help ensure that RWHAP clients maintain access to essential treatment, care, and support services, HRSA HAB released in October 2021 Policy Clarification Notice (PCN) 21-02, Determining Client Eligibility and Payor of Last Resort in the Ryan White HIV/AIDS Program (RWHAP). The updated guidance eliminated the six-month client eligibility recertification requirement for RWHAP programs, including ADAPs, instead allowing recipients and subrecipients to conduct timely eligibility confirmation in accordance with their own policies and procedures. The PCN also states affirmatively that immigration status is irrelevant for the purposes of eligibility for RWHAP services.
As of July 1, 2023, 34 of 51 responding ADAPs have eliminated the six-month recertification requirement.
Changes to Six-Month Recertification Requirements Following Release of PCN 21-02, as of July 1, 2023
See Table 13 for “Other” response details.
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
Tables
Virologic Suppression Outcomes
Eighty-four percent of ADAP clients served by the 51 jurisdictions providing data were reported as being virally suppressed based on their most recent viral load testing result recorded as of December 31, 2022. This is significantly more than the estimated 66% of all people living with diagnosed HIV infection nationally who were virally suppressed, based on most recent viral load test during 2021.
For a five-year comparison, 76% of ADAP clients served in CY2017 were reported as virally suppressed (53 programs reporting data). Sixty-three percent of ADAP clients served in 2014 were reported as virally suppressed, the earliest year in which these data were available (47 programs reporting data). This significant change over time is a testament to the increasing effectiveness of ADAPs in ensuring and reporting optimal health outcomes among their clients served.
ADAP Clients Served, by Viral Load, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
The ADAPs with viral load suppression rates of 90% or better in CY2022 include New Hampshire (97%), Oregon (96%), Illinois (95%), Montana (95%), Massachusetts (94%), Nebraska (94%), Maine (93%), Hawaii (92%), New Mexico (91%), Missouri (91%), Rhode Island (91%), Florida (91%), Wisconsin (91%), Oklahoma (90%), Washington (90%), and New York (90%).
These data illustrate that ADAPs can make meaningful contributions toward widespread viral suppression and, by extension, the EHE initiative.
ADAP Clients Served by Program, by Viral Load, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
ADAP Viral load Suppression Rate, by Clients Served, CY2022
Note: 51 programs reported CY2022 program data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Republic of Palau, US Virgin Islands, and West Virginia did not provide data.
[1] Clients served with full-pay medications only include clients served by the full-pay prescription program for the entire year (or the entirety of a partial year enrolled in the program), with no ADAP coordination with insurance.
[2] Clients served through an ADAP funded insurance program only includes clients who were enrolled in insurance (i.e., Medicare, Medicaid, private insurance) at any point during the year and for whom payment for premiums and/or cost-sharing was made on their behalf using ADAP funds. Cost-sharing includes any copayments, coinsurance, and/or deductible payments required under the client’s insurance plan or program.
[3] Clients “served through full-pay medications and an ADAP funded insurance program” includes clients who either spent part of the year in one program and part of the year in the other or they were primarily served by the ADAP-funded insurance program but required full-pay medication program coverage of medications not covered by their insurance.
[4] Survey respondents provide aggregate race and ethnicity data. Without client-level data, the National RWHAP Part B ADAP Monitoring Project Annual Report is unable to provide breakdowns of intersecting race and ethnicity categories (e.g., number of non-Hispanic Black ADAP clients served).