Section 3. Expanding and Adapting ADAP Service Delivery in a Dynamic Healthcare Environment

ADAPs must continually navigate a dynamic healthcare environment to not only ensure continuity of medication access for clients, but also to meet the evolving and comprehensive pharmacologic needs of low-income PLWHA. The need to expand and adapt ADAP service delivery is not without opportunities, including those associated with the Affordable Care Act and a slow-but-steadily growing number of states moving to expand their Medicaid programs. But there are also challenges, particularly when it comes to coordinating with other highly complex components of the U.S. healthcare system straining under the weight of high prescription drug and insurance costs.  

Full-Pay Medication Programs  

Full-pay medication assistance for uninsured and underinsured PLWHA remain a core service provided by state and territorial ADAPs. In CY2023, more than 138,000 clients served required ADAP medication purchasing support to ensure access to at least one prescription drug essential to comprehensive HIV care. These include antiretroviral drugs products; medications to prevent and treat AIDS-related opportunistic diseases; curative direct acting antivirals for hepatitis C virus coinfection and antiviral therapeutics for chronic hepatitis virus infection; medications for substance use disorders, including overdose prevention; medications to manage cardiovascular, metabolic, and pulmonary diseases that are more common among PLWHA; and medications to support mental health. 

Comparing the 47 ADAPs that provided data for both calendars years, approximately 8,000 (6%) more clients required full-pay medication program assistance from their state ADAP in CY2023.   

Prescription drug purchasing accounted for more than $1.55 billion in gross (pre-rebate and other third-party payments) ADAP spending in CY2023, accounting for approximately 64% of all ADAP program expenditures. In CY2022, among the 47 comparable ADAPs, prescription drugs accounted for $1.39 billion in program expenditures, constituting an 11.5% increase in gross medication purchasing expenditures. According to prescription drug expenditure reporting collected as part of the 2025 Annual Report survey, antiretroviral drug products represented 93% of all CY2023 ADAP drug expenditures with the single-tablet regimen Biktarvy (bictegravir, emtricitabine & tenofovir alafenamide) constituting the majority of antiretroviral drug product expenditures. 

Federal funds used by ADAPs to pay for prescription drugs must be utilized “in the most economically manner feasible.” This includes securing statutorily required discounts on outpatient prescription drugs available to certain federal grantees through participation in the 340B Drug Pricing Program, including state and territorial ADAPs. ADAPs also have access to (often significant) supplemental 340B discounts and/or rebates, depending on the ADAP’s drug purchasing mechanism (Table 16 includes a review of purchasing mechanisms employed by state/territorial ADAPs for both their full-pay medication programs and ADAP-funded insurance programs), including those secured by the Apexus Prime Vendor Program and negotiated by the ADAP Crisis Task Force. The resulting savings has allowed ADAPs to maximize their eligibility criteria, establish comprehensive formularies, and fund treatment support services essential to achieving health equity among PLWHA.  

ADAPs have considerable flexibility in determining not only the composition of their formularies, with some ADAP formularies required to match state Medicaid formularies (7 ADAPs in CY2023), but also the implementation of cost-containment measures, such as maximum cost-per-client caps, maximum prescription number caps, and prior authorization requirements (including clinical criteria, resistance testing, and step therapy requirements).  

ADAP-Funded Insurance Programs 

The Affordable Care Act, signed into law by President Barack Obama in March 2010, has enabled tens of thousands of PLWHA, including ADAP clients, to transition to expanded Medicaid and private insurance available through the federal and state Marketplaces. The ACA’s public and private insurance expansions have had a profound impact on ADAPs and the clients they serve despite fluctuations in federal and state policy affecting Medicaid and private insurance. ADAP continue to support more clients than ever to afford insurance coverage. 

In CY2023, all 49 ADAPs responding to the survey reported using funds for insurance purchasing/continuation, including premium, deductible, and/or copayment/coinsurance payments across multiple insurance types for more than 101,502 clients, representing $745 million  in estimated expenditures (31% of the total ADAP budget for the year), with an average cost per client of $7,344 . In CY2022, ADAPs providing insurance support for 128,418 clients among 47 comparable survey respondents, representing a 21% decrease in the number of ADAP clients receiving premium and/or cost-sharing support in CY2023. Conversely, insurance-related expenditures were considerably lower in CY2022: $698 million with an average cost per client of $5,272. Total and per-client ADAP-funded insurance program expenditures were therefore 6.7% and 39.3% higher in CY2023, respectively, compared with CY2022.  

In CY2023, 34% of ADAP clients served were enrolled in private insurance (e.g., individual market plans purchased on or off Marketplaces or employer-sponsored coverage). Among clients served who were enrolled in private insurance, 50% were enrolled in a qualified health plan (QHP) on the ACA Marketplace – a 0% and 9% increase in the number of ADAP clients with private insurance in CY2022 and CY2018, respectively, with known Marketplace QHP coverage.