Section 2. Meeting the Need: Ensuring Access to Essential Medicines for People Living with HIV/AIDS

In CY2023, among the 47 jurisdictions responding, 240,075 clients were served by ADAPs, representing 20% of the nearly 1.2 million people aged 13 years or older with diagnosed HIV in the United States at the end of 2022. Approximately 46% were served by ADAPs’ full-pay medication programs only,¹ 42% were served by the ADAP-funded insurance program only,² and 11% were served by both the ADAP-funded insurance program and the full-pay medication program.³  

A potential challenge for many ADAPs is the March 31, 2023, end of the Medicaid continuous coverage requirement, which occurred with the Consolidated Appropriations Act of 2023 being signed into law at the end of CY2022. The continuous coverage provision authorized by the Families First Coronavirus Response Act effectively prohibited states from terminating most Medicaid enrollees’ coverage until after the COVID-19 Public Health Emergency. This allowed millions of people, including PLWHA, to stay covered without any interruption during the pandemic. With the “unwinding” of the continuous coverage requirement – the process by which states have resumed annual Medicaid recertification reviews – a sizeable number of low-income PLWHA were expected to lose their Medicaid coverage beginning April 1, 2023, and, consequently, require immediate enrollment (or reenrollment) in ADAP.  

Compared with CY2022 benchmark data across 46 ADAPs, the number of total clients enrolled, new clients enrolled, and clients served increased by 4.7%, 15%, and 4% respectively (Chart 3). An insignificant number of ADAPs were able to provide the total number of new clients enrolled in ADAP during CY2023 who were disenrolled from Medicaid prior to ADAP enrollment, which limits our ability to evaluate the impact of Medicaid “churn” on state ADAPs.  

At the time of this report's publication, a number of state ADAPs have reported to NASTAD their concerns regarding the likelihood of significant reductions in federal funding to state Medicaid programs as part of the Congressional FY2025 budget resolution and reconciliation processes. Sharp decreases in federal funds, notably in the absence of offsets consisting of increases in state dollars to Medicaid programs, are expected to have a profound negative impact on the fiscal and operational capacity of state ADAPs nationwide. 

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 CY2023 in a responding jurisdiction, 41% had incomes at or below 100% of the federal poverty level (FPL). The majority (66%) of ADAP clients served in CY2023 had incomes at or below 200% FPL.   

Less than half (42%) of ADAP clients served in CY2022 were 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 CY2023 (38%) is lower than the proportion reported in CY2018 (46%). The proportion of ADAP clients who are white has increased, from 40% in CY2018 to 54% in CY2023.    

By ethnicity, 33% of ADAP clients served in CY2023 were reported as Hispanic/Latinx, compared with 21% of ADAP clients served in CY2018.⁴ 

The majority of ADAP clients served in CY2023 identified as male (78%) whereas 20% identified as female and 1% as transgender women. Comparatively, 49% and 51% of the U.S. population in 2022 were reported as male and female, respectively.   

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 CY2023, the majority (57%) of ADAP clients served were 45 years or older; 14% were 65 years or older. Comparatively, in CY2018, while the same percentage of clients were 45 years and older, 8% were 65 years or older.  

Virologic Suppression Outcomes 

Eighty-five percent of ADAP clients served by the 47 jurisdictions providing data were reported as being virally suppressed based on their most recent viral load recorded as of December 31, 2023. This is significantly more than the estimated 65% of all people living with diagnosed HIV infection who were virally suppressed, based on most recent viral load test during 2022.  

For a five-year comparison, 80% of ADAP clients served in CY2018 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. These data also illustrate that ADAPs can make meaningful contributions toward widespread viral suppression and, by extension, the EHE initiative.  

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 Hispanic/Latino(a) White-identified ADAP clients served).