Section 1. National RWHAP Part B and ADAP Budgets

Passed by Congress and signed into law by President George H.W. Bush in 1990, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was enacted to create and sustain a responsive care system that spans the continuum of HIV care. This includes: HIV diagnosis; linkage to, and lifelong engagement in, HIV medical care and supportive services; access to safe, effective, and easy-to-use treatment; and durable virologic suppression. Administered by the Health Resources & Services Administration (HRSA) HIV/AIDS Bureau (HAB), the RWHAP was last reauthorized in 2009 and the most recent authorization sunset ended September 30, 2013. In the absence of Congressional action on authorization, the program continues to effectively operate as Congress maintains annual appropriations to it. RWHAP clients demonstrate higher outcomes across the HIV care continuum as compared to all PLWH; in 2022, 89.6% of clients receiving RWHAP medical services were virally suppressed. 

The Part B program is the RWHAP component that ensures state and territorial health departments are funded to provide core medical and support services to eligible clients equitably across urban and rural regions. All 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the six U.S. Pacific Territories/Associated Jurisdictions are eligible to receive Part B program funding. ADAPs are a core medical service of the Part B program charged with ensuring access to lifesaving treatments for HIV (e.g., HIV antiretroviral [ARV] medications, “A1” opportunistic infection [OI] medications) and comorbid conditions that disproportionately impact PLWH and/or affect the adherence to, or effectiveness of, ARV treatment. ADAPs do so through two mechanisms: 1) by paying for the full, negotiated cost of medications for clients; and 2) by paying for a portion or all of a client’s premiums, copayments, cost-sharing, and/or deductibles for private or public insurance.  
 
The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act enables ADAPs to cover a broad array of medications within their formularies for insured and uninsured clients with a limited number of requirements (e.g., all medications and ancillary devices be Food & Drug Administration (FDA)-approved). ADAPs’ expansive medication coverage is critical to their success and consistent with overall goals of the RWHAP to be client-centered, equitable, and comprehensive. 

National RWHAP Part B Program and ADAP Budgets 

Based on a formula and eligibility-based distribution mechanism, RWHAP Part B programs are eligible to receive the following categories of federal funding: Part B Base, Part B Supplemental (if applicable), Part B ADAP Earmark, Part B ADAP Supplemental (if applicable), and ADAP Emergency Relief Funding (if applicable). In FY2023, RWHAP Part B programs (n=59) were Congressionally appropriated a total of $1.3 billion, with $899.7 million (69%) awarded by HRSA to ADAP specifically (i.e., via Part B ADAP Earmark (n=59), Part B ADAP Supplemental (n=7), and ADAP Emergency Relief Funding (n=17)). By comparison, RWHAP Part B programs and ADAPs were awarded $1.3 billion and $899.7 million in FY2022, representing nearly flat changes for each.  

RWHAP Part B programs may choose to allocate a portion or all their Part B Base and/or Part B Supplemental to ADAP. For FY2023, 36 RWHAP Part B programs reported having allocated at least some portion of their RWHAP Part B Base and/or Part B Supplemental to ADAP, representing 5.3% of their overall ADAP budgets. As the largest component to the RWHAP Part B program, ADAPs represented 78% of the overall Part B budget in FY2023 – a 7% increase compared the ADAP budget as a percentage of the overall Part B budget in FY2018.   

Federal awards alone do not meet the needs of RWHAP Part B programs or their clients. Jurisdictions must often use other funding streams to sustain their infrastructure and service delivery, both to meet the goals of federal EHE efforts and challenges associated with emerging health care system dynamics, including the unwinding of the Medicaid continuous coverage requirement associated with the end of the COVID-19 Public Health Emergency. 

Rebates make up the largest proportion of the overall ADAP budget for FY2023 (50%), compared with federal ADAP earmark funding constituting 31% of the overall ADAP budget. Rebates – payments received by many ADAPs from pharmaceutical manufacturers after full or partial payments for medications for clients – account for both the repayment to ADAP from a manufacturer for a drug expenditure and any additional savings generated, which may be used to offset ADAP expenditures and/or allocated to the state or territorial Part B program for allowable services and activities (8% of the overall Part B budget in FY2023).   

Separately from rebates, ADAPs may also generate program income, which includes payments received from third-party payers for the usual and customary cost of medications filled for insured ADAP clients, even if the medications were purchased at 340B (or sub-340B) pricing. In FY2023, $61 million was the amount of program income contributing to the budgets of seven ADAPs, representing 2.3% of the total ADAP budget. Six RWHAP Part B programs reported receiving program income from their ADAPs, totaling $54.8 million.  

Additional sources that may be available to ADAPs include RWHAP Part A allocations (5 states in FY2023), carry-over from prior Part B Base or ADAP Earmark awards, state general revenue funding, and Ending the HIV Epidemic funds (2 states in FY2023).