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National ADAP Monitoring Project Annual Report

SUMMARY AND DETAILED FINDINGS

Acknowledgements

The Henry J. Kaiser Family Foundation (Kaiser) and The National Alliance of State and Territorial AIDS Directors (NASTAD) would like to thank the state ADAP and AIDS program managers and staff for their time and effort in completing the National ADAP Survey which serves as the foundation for this report, and for providing ongoing updates to inform the National ADAP Monitoring Project.

The National ADAP Monitoring Project is one component of NASTAD’s National ADAP Monitoring and Technical Assistance Program which provides ongoing technical assistance to all state and territorial ADAPs. The program also serves as a resource center, providing timely information on the status of ADAPs, particularly those experiencing resource constraints or other challenges, to national coalitions and organizations, policy makers, and state and federal government agencies. NASTAD also receives support for the National ADAP Monitoring and Technical Assistance Program from the following companies: Abbott Laboratories, Gilead Sciences, GlaxoSmithKline, Solvay Pharmaceuticals, and Tibotec Therapeutics. Outside of the National ADAP Monitoring and Technical Assistance Program, NASTAD has a Training and Technical Assistance Cooperative Agreement with the Health Resources and Services Administration (HRSA) to provide technical assistance to ADAPs.

National ADAP Monitoring Project Annual Report

APRIL 2008

Prepared by

The Henry J. Kaiser Family FoundationALICIA L. CARBAUGH

JENNIFER KATES

National Alliance of State and Territorial AIDS DirectorsBETH CRUTSINGER-PERRY

BRITTEN GINSBURG MURRAY C. PENNER

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Summary and Highlights

ADAP SNAPSHOT

➢Number of ADAPs, FY 2007: 58➢Total ADAP Budget, FY 2007: $�.4 billion➢Federal ADAP Earmark Funds, FY 2007: $775 million➢Clients Enrolled, June 2007: �45,799➢Clients Served, June 2007: �0�,987➢Drug Spending, June 2007: $�00 million

TheNationalADAPMonitoringProject’sAnnual Reportis based on a comprehensive survey of all AIDS DrugAssistance Programs (ADAPs), state-level1 programsthatprovideprescriptiondrugmedicationstolow-incomepeople with HIV/AIDS. The National ADAP MonitoringProject is a more than 10-year effort of the NationalAllianceofStateandTerritorialAIDSDirectors(NASTAD)and the Henry J. Kaiser Family Foundation (Kaiser).Each year, the project documents new developmentsandchallengesfacingADAPs,assesseskeytrendsovertime,andprovidesthelatestavailabledataonthestatusof these programs. This report updates prior findingswith data from fiscal year (FY) 2007 and June 2007(unlessotherwisenoted)anddiscussesrecentpolicyandprogrammaticchangesthataffectADAPs.Keyhighlightsfromthisyear’sreportareasfollows:

• The national ADAP client caseload has grown over time. With almost 146,000 enrollees in 2007—and102,000servedinthemonthofJune2007alone—itreacheditshighestlevelsincetheprogrambegan.

• As the nation’s prescription drug safety-net for people with HIV/AIDS,ADAPsaredesignedtoservesome of the most vulnerable people with HIV in thecountry.Mostclientsarelow-income,withmorethanfourin10havingincomesatorbelow100%oftheFederalPovertyLevel(FPLwas$10,210annuallyforafamilyofonein2007),anduninsured(69%),andapproximatelytwo-thirdsarepeopleofcolor.WithoutADAPs,manyof

theseindividualswouldlikelyhavelimitedornoaccesstomedicationsandfall throughthecracks inour largerhealthcaresystem.

• ADAP clients primarily reflect the national epidemic, concentrated in states with the highest numbers of people living with HIV/AIDS. Ten states accountedfor two-thirds (67%) of total client enrollment in June2007. Regionally, more than a third (37%) of clientsenrolledlivedintheSouth,27%intheWest,25%intheNortheast,and11%intheMidwest.2

• The 2006 reauthorization of the Ryan White Program, the federal program under which ADAPswereestablished,changed theway inwhich federalfunding is distributed to states for ADAPs. It alsoinstituted new ADAP policies such as a minimumdrugformularyrequirementforantiretrovirals,thefirstsuchrequirementintheprogram’shistory.Whiletheimplications of these recent changes are still beingplayed out at the state level, they have introducedboth new opportunities and new challenges forADAPs. For example, the funding formula changehas resulted in fluctuations in the amount of ADAPfundingreceivedbystatesbetweenFY2006andFY2007, and may continue to do so. Additionally, thenew formulary requirement has served to expandaccesstomedications inafewstatesbutmayposeresourcechallengesinothers,particularlyasnewer,butusuallymoreexpensive,classesofantiretroviralsareintroduced.

• There is good news for ADAPs, as several recent factors have combined to ease past pressures,although relief has not been felt equally across thecountryanditslongevityisuncertain.ForthefirsttimesincetheMonitoringProjectbegantrackingADAPs,waitinglistswerenearlyeliminatedinthemostrecentperiod. In addition, most ADAPs increased client

Hispanic26%

AfricanAmerican

33%

White35%

Unknown/Other 6%

101–200% FPL32%

201–300% FPL14%

>300% FPL 7%

Unknown 4%

IncomeRace/Ethnicity

100% FPL43%

Profile of ADAP Clients, June 2007

Note:53ADAPsreporteddata.AmericanSamoa,FederatedStatesofMicronesia,Guam, Marshall Islands, and Northern Mariana Islands did not report data. TheFederalPovertyLevel(FPL)was$10,210(slightlyhigherinAlaskaandHawaii)forahouseholdofone.Percentagesmaynottotal100%duetorounding.

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enrollment and added medications from two newdrugclassesalmostimmediatelyupontheirapproval,despitehavingamulti-monthgraceperiod fordoingso. Among the factorscontributing to theeasingofpastpressuresformanystateswere:

–President’s ADAP Initiative (PAI):ThePAIprovidedadditionalone-timefunding3to10stateswithwaitinglists, resulting in a drop in the number of peopleon waiting lists across the country (although noteliminatingwaitinglistscompletely;attheendofthePAI in 2006, more than 300 additional individualswerestillonwaitinglistsinsixstates).

–Medicare Part D: Several ADAPs reported thattheintroductionofMedicarePartDin2006helpedtoeaseconstraintsand/orprovideanewavenuefor prescription drugs for people with HIV. Forexample,manyADAPshavebeenable to reducecostsby transitioning frompayingall prescriptiondrug costs for Part D-eligible clients to coveringtheir “wrap around” costs such as co-payments,monthly premiums, or costs when beneficiariesreachthe“coveragegap”intheirPartDplans.

–Non-Federal Funding Sources: Over time, non-federal funding sources—particularly state generalrevenue support and drug rebates—have becomecriticalpartsof theADAPbudget. States,althoughnotrequiredtodoso,havegenerallyactedtoprovideadditionalfundingtoADAPsatkeytimes,sometimesin response to state-level advocacy efforts. Inaddition,theeasingoftheeconomicdownturnthathitstateshardintheearlierpartofthedecadelikelyledtosomestatesincreasingtheircontributionstoADAPthis year. Moreover, because of the uncertainty ofADAPfundingfromyeartoyear,ADAPshavebecomeincreasingly sophisticatedat seekingother sourcesofrevenue,particularlypharmaceuticalmanufacturerdrugrebates,whichnowappeartobeamainfactorallowing most ADAPs to continue to meet clientdemandandevenexpandaccessinsomecases.

–ADAP Supplemental Drug Treatment Grants:RyanWhiteReauthorizationincreasedtheamountof fundingavailable forADAPSupplementalDrugTreatmentGrants,aset-asideofthefederalADAPearmarkdesignedtoprovideadditionalfundingtostates with significant ADAP program limitations.

The Ryan White CARE Act, now called “Title XXVI of the PHS Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006,” or the “Ryan White Program,” is the single largest federal program designed specifically for people with HIV/AIDS. ADAPs, which began as AZT Assistance Programs in the �980s when federal assistance was initially provided to states for purchasing the first approved antiretroviral medication, were incorporated into the Ryan White Program when it was first enacted in �990. The Ryan White Program was reauthorized in both �996 and 2000, and was reauthorized for the third time in December 2006. Whereas all prior authorizations were for five-year periods, the recent authorization was for three years.

Each reauthorization of the Ryan White Program has brought changes and new developments for ADAPs, as well as for other parts of the Ryan White Program, reflecting both past experience and anticipated issues and challenges moving forward. The �996 reauthorization created the federal ADAP earmark. The 2000 reauthorization created the ADAP Supplemental Drug Treatment Grant Program, included a provision allowing ADAPs to use funds for insurance purchasing and maintenance, and increased their flexibility to provide other limited services (e.g., adherence support and outreach).

The 2006 reauthorization brought further changes to ADAPs, including:

Minimum ADAP Formulary: For the first time in the program’s history, ADAPs are required to cover at least one

medication from each of the approved antiretroviral drug classes, as indicated in the Department of Health and Human Services “Guidelines for the Use of Antiretroviral Agents in HIV-�-Infected Adults and Adolescents” (currently there are six classes subject to the requirement, but this provision will apply to any future classes of antiretroviral medications that are incorporated into the Guidelines). HRSA instituted the new provision into policy, effective July �, 2007.

Earmark Formula: The formula used for distribution of federal ADAP earmark funding changed. Previously, estimated living AIDS cases were utilized in determining ADAP formula awards. The new formula has moved from estimated living AIDS cases to actual AIDS cases and also includes HIV cases. This change has resulted in some funding shifts for ADAP earmark awards although such shifts were limited by the hold harmless requirement which ensured each state received at least 95% of its FY 2006 award.

ADAP Supplemental: Several changes were made to the ADAP supplemental grant program. The set-aside increased from three to five percent of the ADAP earmark; eligibility requirements changed; and matching requirements can now be waived if certain requirements are met.

Beyond these ADAP-specific changes, reauthorization has brought changes to other parts of the Ryan White Program that continue to affect ADAPs, such as changes in the way overall state Part B funding is distributed across the country, which in turn affects the amount of funds states have available to provide to ADAPs. ◗

RyAN WHiTE REAuTHORizATiON

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This resulted in the first increase in fundsavailable through the ADAP Supplemental sinceFY 2003, and likely contributed to the easingof fiscal pressures in those states that receivedincreases(13states)orfirst-time(3states)ADAPsupplementalfunding.

• Despite these factors, there is a concern for the future. ADAPfundinglevelsandbudgetcompositionarehighly variable fromyear to year,with revenuesources often being triggered as “levers” that riseandfalldependingontheamountoffederalfundingavailable.TrenddataindicatethatwhenoneADAPrevenuesourcedecreases,othersoftenincreasetofillthegap.Forexample,asgrowthinfederalADAPearmark fundinghasslowed in recentyears—evendeclining over the last year for the first time sinceit began—other funding sources, such as drugrebates, have been sought more actively. These“levers,”however,areseldompermanentandusuallyunpredictable.TheonlytwoADAPfundingsourcesthatincreasedoverthelastperiodweredrugrebatesand theADAPSupplemental;allothersdecreased,includingstate funding,whichhashistoricallybeenakeydriverofADAPbudgetgrowth.Additionally,itisstillnotclearhowtherecentchangesintheRyanWhite Program will affect ADAPs over time; ADAPearmarkfunding,forinstance,isstillexpectedtoshiftstate-by-stateasholdharmlessandotherprovisionsinthelawplayout.Finally,therearerecentsignalsofanewstate-leveleconomicdownturn,withsomestatesalreadyreportingoverallbudgetshortfallsforFY 2008 and/or expecting shortfalls for FY 20094;thesestatesincludesomeofthosewiththelargestADAPcaseloads,anditisunknowniforhowADAPswill be affected. Ultimately, the number of clientsservedbyADAPswillcontinuetobedeterminedbythe amount of funding the programs receive eachyear and may not correspond to the number ofpeoplewhoneedprescriptiondrugsortothecostsofmedications.

The National ADAP Monitoring Project will continue toassess these issues,particularly theongoing impactofRyanWhiteReauthorizationandtheroleofthelargerstatefiscalenvironment,overthenextyearandprovidedataon thecritical roleADAPsplay inproviding low-incomeindividualswithHIVaccesstoneededmedications.

A background and overview on ADAPs, followed bydetailedfindingsonclients,drugexpenditures,budgets,eligibility, and other key aspects of the program, arebelow. Chartsanddetailed tableswithstate-leveldatacanbefoundinthefullreportandonline.

Background and Overview of ADAPsThe AIDS Drug Assistance Program (ADAP) of the RyanWhiteComprehensiveAIDSResourcesEmergency(CARE)Act,nowcalled“TitleXXVIofthePHSActasamendedbytheRyanWhiteHIV/AIDSTreatmentModernizationActof2006”,orthe“RyanWhiteProgram,”5,6isacriticalsourceofprescriptiondrugsfor low-incomepeoplewithHIV/AIDSin the United States who have limited or no prescriptiondrug coverage. With almost 146,000 enrollees, ADAPsreach about three in 10 people with HIV estimated to bereceivingcarenationally.7InthemonthofJune2007alone,ADAPs provided medications to nearly 102,000 clientsandinsurancecoverageformedicationsandothermedical

KEy DATES iN THE HiSTORy OF ADAPS

1987: First antiretroviral (AZT, an NRTI) approved by the FDA; Federal government provides grants to states to help them purchase AZT, marking beginning of federally-funded, state administered “AZT Assistance Programs.”

1990: ADAPs incorporated into Title II of the newly created Ryan White CARE Act.

1995: First protease inhibitor approved by FDA, and the highly active antiretroviral therapy (HAART) era begins.

1996: First reauthorization of CARE Act – Federal ADAP earmark created; first non-nucleoside reverse transcriptase inhibitor (NNRTI) approved by FDA.

2000: Second reauthorization of CARE Act, changes for ADAPs include: allowance of insurance purchasing and maintenance; flexibility to provide other limited services (e.g., adherence support and outreach); and creation of ADAP supplemental grants program, using a set-aside of the federal ADAP earmark for states with “severe need.”

2003: NASTAD’s ADAP Crisis Task Force formed to negotiate with pharmaceutical companies on pricing of antiretroviral medications; first fusion inhibitor approved by FDA.

2004: President’s ADAP Initiative (PAI) announced, allocating $20 million in one-time funding outside of the ADAP system to reduce ADAP waiting lists in �0 states.

2006: Third reauthorization of the CARE Act, now called, “Title XXVI of the PHS Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006” or the “Ryan White Program.” Changes for ADAP include: new formula for determining state awards which incorporates living HIV and AIDS cases; new minimum formulary requirement; and changes in ADAP supplemental set-aside and eligibility.

2007: New minimum formulary requirement effective July �; first CCR5 antagonist and integrase inhibitor approved by FDA. ◗

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caretothousandsmore. Inadditiontohelpingtofillgapsin prescription drug coverage, ADAPs serve as a bridgebetweenabroaderarrayofhealthcareandsupportiveservicesfunded by the RyanWhite Program, Medicaid, Medicare,andprivateinsurance.AsthenumberofpeoplelivingwithHIV/AIDSintheU.S.hasincreased,largelyduetoadvancesinHIVtreatment,anddrugpriceshavecontinuedtorise,theimportanceofADAPshasgrownovertime.

The purpose of ADAPs, as stated in Ryan Whitelegislation,isto:

…provide therapeutics to treat HIV disease or prevent the

serious deterioration of health arising from HIV disease in

eligibleindividuals,includingmeasuresforthepreventionand

treatmentofopportunisticinfections…5

ADAPs accomplish this through two main activities: byprovidingFDA-approvedHIV-relatedprescriptiondrugstopeoplewithHIV/AIDSandbypayingforhealth insurancethat includescoverageofHIV treatments. IndividualsareeligibleforADAPwhentheycandemonstratetheyarelowincomeandhavelimitedornoprescriptiondrugcoverage.

ADAPs began serving clients in 1987, when Congressfirst appropriated funds ($30 million over two years8)to help states purchase AZT, the only FDA-approvedantiretroviraldrugatthattime.In1990,thesefederally-funded, state-administered“AZTAssistancePrograms”were incorporated into the newly created Ryan WhiteProgram under Title II (grants to states, now calledPartB)andbecameknownas“AIDSDrugAssistancePrograms,”orADAPs. TheRyanWhiteProgram is the

Each year, Congress specifically earmarks federalfundingforADAPsthroughRyanWhitePartB(fundingfor care grants to states). Prior to the most recentreauthorizationoftheRyanWhiteProgramin2006,theformulausedtoallocatethesefundstostatejurisdictionseachyearwasbasedontheirproportionofthenation’sestimatedlivingAIDScases.The2006Reauthorizationchanged the formulabymoving fromestimated livingAIDScasestoactualAIDScasesandbyincludingHIVcasesintheformula.AIDScasecountsaredeterminedby the Centers for Disease Control and Prevention(CDC) as reported by states. HIV case counts arenowdeterminedinoneoftwoways:(1)ascertifiedbythe CDC in states with “mature” HIV name reportingsystems;or(2)asreportedtotheHealthResourcesandServicesAdministration(HRSA),byjurisdictionswithoutmatureHIVnamereportingsystems,whichthenappliesafivepercent“duplication”penaltytothecount.Oncethesecountsaredetermined,ajurisdiction’sproportionoflivingAIDSandHIVcasesisappliedtothefundingavailable through the ADAP earmark to determinetheawardamount. InFY2007,58 jurisdictionswereeligible for federal ADAP earmark funding, includingall50states,theDistrictofColumbia,PuertoRico,theU.S.VirginIslands,AmericanSamoa,FederatedStatesofMicronesia,Guam,Marshall Islands,andNorthernMarianaIslands;PalauwaseligibletoreceivefundingbutdidnotreportanyHIV/AIDScasesandthereforedidnotreceiveafundingaward.

Stateswithonepercentormoreof reportedAIDScasesduringthemostrecenttwo-yearperiodmustmatch (with non-federal contributions) their overallRyanWhitePartBaward,whichincludestheADAPearmark, according to an escalated matching rate(based on the number of years in which the statehasmettheonepercentthreshold).Statesarenot

required,however,touseallorevenpartofthestatematch forADAPand thematchmayconsist of in-kindordollarcontributionsfromthestate.

The 2006 Reauthorization increased the set-asideforADAPSupplementalDrugTreatmentGrants fromthreetofivepercentoftheADAPearmarkandmadechangestostateeligibilitycriteriaforthesefunds.Now,Supplementalgranteligibilityisnowbasedoncurrent“demonstratedneed”asmeasuredbyADAP incomeeligibilitycriteria,formularycomposition,thenumberofeligibleindividualstowhomastateisunabletoprovidemedications,andanunanticipatedincreaseineligibleindividualswithHIV/AIDS(prioreligibilitywasbasedon“severeneed”asdefinedbyaJanuary2000standard).Awardamountsarebasedontheproportionofstates’HIVandAIDScasesinthosejurisdictionsapplying.Inaddition,whileADAPseligibleforsupplementalawardsare required to provide a $1 state match for every$4 of federal supplemental funds, the most recentreauthorizationallowsstates toapply forawaiverofthisrequirementiftheyhavemetotherRyanWhitePartBmatchingrequirements,ifapplicable.InFY2007,16ADAPsreceivedawardfunding(anadditional18wereeligiblebutdidnotapply).

ItisimportanttonotethattheADAPfiscalyeardiffersfromthefederalandstatefiscalyearperiods:

ADAPfiscalyear:April1–March31

Federalfiscalyear:October1–September30

Statefiscalyear(formoststates):July1–June30

Forexample,theADAPFY2007beganonApril1,2007andendedonMarch31,2008.TheFederalFY2007beganonOctober1,2006andendedonSeptember30,2007. TheStateFY2007, inmoststates,beganJuly1,2007andwillendonJune30,2008. ◗

AllOCATiON OF FEDERAl FuNDiNg TO ADAPS & STATE MATCH REquiREMENTS

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nation’s third largestsourceof federal funding forHIVcare,afterMedicaidandMedicare.9

Since FY 1996, Congress has specifically earmarkedfundingforADAPswithinPartBoftheRyanWhiteProgram,which is allocated by formula to states.10 The ADAPearmark is the largest component of the overall ADAPbudget,althoughavailablefundsfromitdecreasedslightlybetweenFY2006andFY2007(byonepercent)forthefirsttimeinitshistory.11ManyADAPsalsoreceivefundingfromother sources, including state general revenue support,12

fundingfromotherpartsoftheRyanWhiteProgram,andpharmaceuticalmanufacturers’ drug rebates.Theseotherfundingsourcesarehighlyvariableandlargelydependentonstateandlocalpolicydecisions,differingADAPprogrammanagementstrategies,andresourceavailability.

The Health Resources and Services Administration(HRSA) of the Department of Health and HumanServices(DHHS)isthefederalagencythatadministersthe Ryan White Program, including ADAPs. In FY2007, 58 jurisdictions received federal ADAP earmarkfunding,includingall50states,theDistrictofColumbia,PuertoRico, theU.S.Virgin Islands,AmericanSamoa,FederatedStatesofMicronesia,Guam,MarshallIslands,and Northern Mariana Islands; Palau was eligible toreceive fundingbutdidnot reportanyHIV/AIDScasesandthereforedidnotreceiveafundingaward.

EachstateadministersitsownADAPandisgivenflexibilityundertheRyanWhiteProgramtodesignmanyaspectsof its program, including client eligibility guidelines,drug purchasing and distribution arrangements, and tosome extent, drug formularies. There is no standardclient income eligibility level required by law, althoughclients must be HIV-positive, low-income, and under-or uninsured. The reauthorization of the Ryan WhiteProgram in 2006 instituted a new “minimum druglist,” to be determined by the Secretary of Health andHumanServices, toensure thatantiretrovirals fromthecore antiretroviral drug classes are included on ADAPformularies. HRSA interpreted this requirement tomandatetheinclusionofatleastoneantiretroviralfromwithineachantiretroviraldrugclass,asspecifiedbytheDHHSguidelinesonantiretroviraltreatment,onallADAPformularies,a requirement thatwent intoeffectonJuly1,2007.ADAPsstilldeterminehowmanymedicationsfromwithineachantiretroviralclasstooffer,what,ifany,non-antiretroviralmedicationsarecovered,andwhethercost-sharing, quantity limits, or drug-specific eligibilitycriteriaareinstituted.

LikeallRyanWhiteprograms,ADAPsserveas“payeroflastresort”;thatis,theyprovideprescriptionmedicationsto,orpayforhealthinsurancepremiumsormaintenance(co-

paymentsor deductibles) for, peoplewithHIV/AIDSwhennootherfundingsourceisavailabletodoso.DemandforADAPsdependsonthesizeoftheprescriptiondrug“gap”thatADAPsmustfill intheirjurisdiction—largergaps,suchasinstatesthathavelessgenerousMedicaidprograms,maystrainADAPresourcesfurther.ButADAPsarediscretionarygrantprograms,notentitlements,13andtheirfundingmaynotcorrespondtothenumberofpeoplewhoneedprescriptiondrugs or to the costs of medications. Therefore, annualfederal appropriations, and where provided, state fundingandcontributionsfromothersources,determinehowmanyclients ADAPs can serve and the level of services theycanprovide.Inaddition,giventhatADAPsareanintegralcomponent of the larger RyanWhite system, the fundinglevelsandcapacityofotherRyanWhitecomponentsmayalsoaffectclientaccesstoADAPs.TrenddataindicatethatwhenoneADAPrevenuesourcedecreases,othersappeartoincreasetofillthegap.However,these“levers”areseldompermanentandusuallyunpredictable.

Detailed FindingsThe detailed findings below are based on acomprehensive survey sent to all 58 jurisdictions thatreceived federal ADAP earmark funding in FY 2007;53 responded (see Methodology). All data are fromFY 2007 and June 2007, unless otherwise noted(supplementaldatacollectionwasconducted inselectareas). For the first time, regional comparisons areprovidedwhereavailable.2

CliENTS, DRug EXPENDiTuRES, AND PRESCRiPTiONS

ADAP Clients ADAP client enrollment and utilization were at theirhighestlevelssincetheMonitoringProjectbegantrackingADAPs.Clientdemographics varyby stateand region,butnationalADAPclientdemographicshave remainedfairlyconstantoverthecourseoftheMonitoringProjectwith ADAPs primarily serving low-income, uninsuredclients,mostofwhomareminorities.

• 145,799 clients were enrolled in ADAPs nationwideasofJune2007,representingatwopercentincreaseover June 2006 (see Chart 1 and Table I). Thenumber of clients enrolled ranged from a low of 57in Alaska to a high of 28,723 in California. ClientenrollmentisanimportantmeasureoftheaggregatenumberofclientswhouseADAPservicesovertime.More clients are typically enrolled in ADAPs thanseek services in any given month; this differencecomes as a result of changing clinical needs,

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differing prescription lengths, and fluctuation in theavailabilityofotherresourcestopayformedications.SomeindividualscycleonandoffADAPthroughoutayear,particularly thosewithMedicaidorMedicarePart D coverage. Medicaid beneficiaries may facelimits in theircoverage insomestatesand/orare inthe Medicaid spend-down process. Medicare PartDbeneficiariesmightnotuseADAPuntiltheyreachthe coverage gap (the time when Medicare Part Dbeneficiariesareresponsibleforalltheirdrugcosts),necessitatingareturntoADAP.

• ADAPsprovidedmedicationsto101,987clientsacrossthecountryinJune2007,about70%ofthoseenrolledandasixpercentincreaseoverJune2006.ADAPsalsopaidforinsurancecoverage(premiums,co-payments,and/ordeductibles)for20,960clients,someofwhommayhavealsoreceivedmedications(seeCharts2and39andTablesIandXXI).

• Mirroring the national epidemic, most ADAP clientsareconcentratedinstateswiththehighestnumbersofpeoplelivingwithHIV/AIDS.Forexample,tenstatesaccounted for two-thirds (67%) of total enrollmentin June 2007; five states accounted for half (51%:California,NewYork,Texas,Florida,andPennsylvania).Thedistributionissimilarforclientsserved.Regionally,morethanathird(37%)ofclientsenrolledlivedintheSouth, 27% in theWest, 25% in the Northeast, and11%intheMidwest(again,breakdownsaresimilarbyclientsserved).

• InJune2007,clientdemographicswereasfollows(seeCharts5–10andTablesV–X):

–Nationally, African Americans and Hispanicsrepresented 59% (33% and 26%, respectively)of clients served. Asian/Native Hawaiian/PacificIslanders and Alaskan Native/American Indianscombined represented approximately two percentofthetotalADAPpopulation.Non-Hispanicwhitescomprised 35%. Regionally, the South has thehighest percentage of African Americans amongclientsserved(44%ofclientsservedintheregion);theWesthas thehighestpercentageofHispanics(35%ofclientsservedintheregion)andtheMidwesthasthehighestpercentageofNon-Hispanicwhites(50%ofclientsservedintheregion).

–More than three-quarters (77%) of ADAP clientsweremen.

–Half of clients (50%)werebetween theagesof25and 44, followed by those between the ages of 45and64(43%).

–Three-quarters(75%)wereatorbelow200%oftheFederalPovertyLevel (FPL), includingmore thanfourinten(43%)whowereatorbelow100%FPL.In 2007, the FPL was $10,210 annually (slightly

higher in Alaska and Hawaii) for a family of one.Regionally,84%ofclients in theSouthwere low-income (200% or less of the FPL) compared to67% inboth theWestandNortheastand79% intheMidwest.

–AmajorityofADAPclients(69%)wereuninsured,with few reporting any other source of insurancecoverage—15% private, 12% Medicare, and/ortwo percent Medicaid; two percent were dualbeneficiaries of both Medicaid and Medicare.For those with other sources of coverage, ADAPfills the gaps, such as paying client cost-sharingrequirements (e.g., co-payments, deductibles,etc.) and/or providing additional medications forthose clients who may be subject to monthly orannual prescription drug limits under other formsof coverage. Insurance coverage in June 2007issimilar tocoverage reported for thesame timeperiod inthe last twoyears,withtheexceptionofMedicaid (six percent in June 2006 and 10% inJune2005).

–More than half of ADAP clients (51%) had CD4counts of 350 or below (at time of enrollment oratrecertification),onepotentialindicationofmoreadvanced HIV disease. Higher CD4 counts mayrepresentsuccessfultreatmentorearlyinterventionefforts.CD4countinformationwasavailablefrom32ADAPsand reflects clientsenrolled inADAPsover the last 12 months or the most recent 12months forwhichdataareavailable. Inaddition,ADAPsarerequiredtorecertifyclientstwotimesayear.Asaresult,thesefiguresdonotnecessarilyrepresentCD4countsofnewclients.

ADAP Drug Expenditures and Prescriptions

Thedistributionofdrugexpendituresandprescriptionsvariesacrossstatesandregions,likelyreflectingdifferingformularies, drug prices, and prescribing patterns.Antiretrovirals,thestandardofcareforHIV,accountforthemajorityofADAPdrugexpendituresandprescriptionsfilled.(Note:dataondrugexpendituresandprescriptionsarebasedonJune2007.)

• ADAPdrugexpenditureswere$100,147,921inJune2007,afivepercentincreaseoverJune2006,rangingfrom a low of $21,195 in Maine to a high of $22.3million inCalifornia (seeChart11andTables I andIII).Tenstatesaccountedforthree-fourths(75%)ofall drug spending; five states (California, NewYork,Texas,NewJersey,andFlorida)accounted foroverhalf(59%)ofalldrugspending.

• ADAPsspendmostoftheirfundingdirectlyonmedicationswith estimated annualized drug spending14 reachingapproximately$1.2billion in2007,or84%ofthenational

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ADAP budget. In addition to providing medications, 39ADAPs spent $8.8 million on insurance purchasing/maintenanceinJune2007,anincreaseof63%overJune2006, and report that FY 2007 spending on insurancetotaled$74.5million(seeChart39andTableXXI).15Twelve

ADAPsalsoreportedspending$9.5milliononmedicationadherence,outreach,andmonitoringactivities.

• Percapitadrugexpenditureswere$982inJune2007(seeChart13andTableII),oranestimated$11,784inannualpercapitadrugcosts.PercapitaexpendituresinJune2007rangedfromalowof$116inOregonto$3,328inKansas(seeTableII),againlikelyreflectiveofdiffering ADAP formularies, purchasing mechanisms,insurance programs, and/or prices paid by ADAPsacrossthecountryfordrugs.

• ADAPs filled a total of 344,600 prescriptions in June2007,rangingfromalowof70inNorthDakotatoalmost76,000inCalifornia(seeChart16andTableIV).

• Most ADAP drug spending is for antiretrovirals16 (89%in June 2007). While this is in part due to their highutilization,itisalsorelatedtotheircosts,astheyrepresentagreatershareofexpendituresthanprescriptionsfilled(nearly60%).The29“A1”drugshighlyrecommendedforthepreventionandtreatmentofHIV-relatedopportunisticinfections (OIs),17,18 accounted for two percent ofexpenditures and nine percent of prescriptions (seeCharts15and16andTablesIIIandIV).

• Theaverageexpenditureperprescriptionwas$291. Itwas significantly higher for antiretrovirals ($433) thannon-antiretrovirals($75for“A1”OIsand$83forallotherdrugs).Amongantiretroviraldrugclasses,fusioninhibitorsrepresented the highest expenditure per prescription($1,323), followed by nucleoside reverse transcriptaseinhibitors(NRTIs,$401),proteaseinhibitors($391),andnon-nucleosidereversetranscriptaseinhibitors(NNRTIs,$281). Per prescription expenditures for multi-classcombinationproductswere$902(seeChart14).19

Trends in Clients and Drug Expenditures

• Client enrollment has grown over time, reachingits highest level (145,799 in June 2007) since theprogram began, although the rate of growth hasslowed in recent years (enrollment rose by twopercentbetweenJune2006andJune2007).

• Client utilization (the number of clients receivingprescription medications) has grown significantlysince 1996 (226% among the same 47 ADAPsreportingdata inbothperiods),butatadecreasingrateinrecentyearsandhasgenerallylaggedbehindtherateofincreaseindrugexpenditures(seeCharts3, 4, and 12). Client utilization overall increasedby five percent between June 2006 and June 2007(amongthesame47ADAPs).Asexpected,theonepercentdecreaseinFY2006clientutilizationwasa

NNRTIs6%

“A1” Ols2%

All Other9%

Total = $100.1 Million

NRTIs37%

Protease Inhibitors27%

Multi-ClassCombination

Products16%

Fusion Inhibitors1%

ADAP Drug Expenditures, by Drug Class, June 2007

Note: 5� ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Nevada, New Mexico, and Northern Mariana Islands did not report data. Percentages may not total �00% due to rounding. NRTIs = Nucleoside Reverse Transcriptase Inhibitors; NNRTIs = Non-Nucleoside Reverse Transcriptase Inhibitors; “A�” OIs = Drugs recommended (“A�”) for the prevention and treatment of opportunistic infections (OIs). See Table III.

NNRTIs7%

“A1” Ols9%

All Other31%

Total = 344,600 Prescriptions

NRTIs27%

Protease Inhibitors20%

Multi-ClassCombination Products

5%

Fusion Inhibitors<1%

ADAP Prescriptions Filled, by Drug Class, June 2007

Note: 52 ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Nevada, and Northern Mariana Islands did not report data. Percentages may not total �00% due to rounding. NRTIs = Nucleoside Reverse Transcriptase Inhibitors; NNRTIs = Non-Nucleoside Reverse Transcriptase Inhibitors; “A�” OIs = Drugs recommended (“A�”) for the prevention and treatment of opportunistic infections (OIs). See Table IV.

8

temporaryshiftduetoimplementationoftheMedicarePart D benefit. The move of Part D-eligible ADAPclients into the new benefit provided some ADAPsshort-termclientstability.

• Drug spending by ADAPs has increased more thansix-fold (525%) since 1996, more than twice therate of client growth over this same period (amongthesame46ADAPsreportingdatainbothperiods).It too has continued to increase but at slowerrates. Between June 2006 and June 2007, drugexpendituresgrewsixpercent (among thesame46ADAPs).Asobservedwithclientutilizationlastyear,

therewasaone-timedecreaseindrugexpenditures(sevenpercentbetweenJune2005andJune2006),similarlyattributabletotheexpectedone-timemoveofMedicare-eligibleADAPclientsintoPartD,and/orthetransitiontoADAPspayingforclientcost-sharingforMedicarePartD(versusdirectdrugexpenditures).

EligiBiliTy CRiTERiA AND FORMulARiES

ADAP Eligibility Criteria

ADAPeligibilitycriteriaaredeterminedbyeachstate,althoughclientsarerequiredbylawtobeHIV-positive,low-income,andmusthaveinsufficientornoinsurance.There is no minimum income eligibility set by thefederalgovernment.EligibilitydecisionsreflectbudgetconditionswithinastateandthesizeofthepopulationlivingwithHIV/AIDSneedingservices. Asa result ofthesefactors,eligibilitycriteriavarybystate,althoughsomeADAPssettheireligibilitycriteriatobeconsistentwithotherhealthprogramswithintheirstate(seeCharts17and18andTableXI).

• All ADAPs require that individuals provide clinicaldocumentationofHIVinfection.SevenADAPsreportedadditionalclinicaleligibilitycriteria(e.g.,specificCD4orviralloadranges).

• ADAP income eligibility in June 2007 ranged from200%FPLinninestatesto500%FPLinsix.Overall,25 states set income eligibility at greater than 300%FPL,fourmorestatesthanlastyear’sreport(Arkansas,Colorado, andWyoming raised their income eligibilitylevels andNewMexicodidnot report data last year).Nineteen states were between 201% and 300% FPL.Inaddition tousing income todetermineeligibility,18ADAPs reported having asset limits in place in June2007.

• All ADAPs require enrollees to be residents of thestate in which they are seeking medications. ManyADAPsrequiredocumentationof residencyanda fewhavespecific residency requirements (e.g.,mustbearesidentfor30days).

ADAP Formularies

ADAP formularies (the list of drugs covered) varysignificantlyacross thecountry. Until themost recentreauthorizationof theRyanWhiteProgram, therewasnominimumrequirementforADAPformularies,althoughfederal law specified that states use ADAP funds “toprovidetherapeuticstotreatHIVdiseaseorpreventtheseriousdeteriorationofhealtharisingfromHIVdiseasein eligible individuals, including measures for the

American Samoa

Federated States of Micronesia

Guam

Marshall Islands

Northern Mariana Islands

Puerto Rico

Virgin Islands (U.S.)

RIOR

AZ

HI

AK

NM

TX

OK

LAMS

AL

SC

NC

VA

NJ

MA

CT

WVUTNV

COCA

WA

ID

WY

TN

KYMO

IL

MN

WI

IANE

KS

ND

SD

IN

MI

OH PA

ME VT NH

NY

MT

GA

FL

AR

Income eligibility greater than 300% FPL (25 ADAPs)

Income eligibility between 201% FPL and 300% FPL (19 ADAPs)

Income eligibility at 200% FPL (9 ADAPs)

Not Reported (5 ADAPs)

DEMD

DC

ADAP income Eligibility, December 31, 2007

Note: 5� ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, and Northern Mariana Islands did not report data. The 2007 Federal Poverty Level (FPL) was $�0,2�0 (slightly higher in Alaska and Hawaii) for a household of one. See Table XI.

American Samoa

Federated States of Micronesia

Guam

Marshall Islands

Northern Mariana Islands

Puerto Rico

Virgin Islands (U.S.)

RIOR

AZ

HI

AK

NM

TX

OK

LAMS

AL

SC

NC

VA

NJ

MA

CT

WVUTNV

COCA

WA

ID

WY

TN

KYMO

IL

MN

WI

IANE

KS

ND

SD

IN

MI

OH PA

ME VT NH

NY

MT

GA

FL

AR

Covers all antiretrovirals in all drug classes: NRTIs, NNRTIs, Protease Inhibitors, Fusion Inhibitors, CCR5 Antagonists, and Integrase Inhibitors, as well as Multi-Class Combination Products (29 ADAPs)

Does not cover all antiretrovirals in all drug classes (24 ADAPs)

Not Reported (5 ADAPs)

DEMD

DC

ADAP Formulary Coverage of Antiretroviral Drugs, December 31, 2007

Note: 5� ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, and Northern Mariana Islands did not report data. NRTIs = Nucleoside Reverse Transcriptase Inhibitors; NNRTIs = Non-Nucleoside Reverse Transcriptase Inhibitors. See Table XII.

9

prevention and treatment of opportunistic infections.”Effective July 1, 2007, all ADAPs were required toincludeatleastonedrugfromeachantiretroviraldrugclass;ADAPshaveagraceperiod20withinwhichtheymustaddadrugfromanewclassandatthetimeofthissurvey,thegraceperiodwasstillineffectfortwonewantiretroviralclasses(CCR5antagonistsandintegraseinhibitors), for which the first medications were onlyapproved in August and October, respectively. Theminimum formulary requirement does not apply tomulti-class combination products (not considered a

uniqueclassofdrugs),drugsforpreventingandtreatingopportunisticinfections(OIs),hepatitisCtreatments,ordrugsforotherHIV-relatedconditions(e.g.,depression,hypertension, and diabetes) (see Charts 19–21 andTablesXIIandXIII).

• AsofDecember2007,ADAPformulariesrangedfrom28 drugs covered in Louisiana to more than 460 inNewYork,aswellasopenformularies21infourstates(Massachusetts, New Hampshire, New Jersey, andOregon).

SincethebeginningofADAP,stateshavestruggledto meet client demand while facing growingprescriptiondrugcosts. Asaresult,manyADAPshave had to make difficult decisions betweenclient access and services, sometimes leading tothe implementationofwaiting listsandothercost-containmentmeasures.

In certain cases, states have capped programenrollment until more resources become available.When an enrollment cap is reached, the nextindividual who seeks services cannot get themthroughtheADAP.Statesthathaveenrollmentcapshaveoftenturnedtowaitinglistsinordertofacilitateclient access once the program can accommodatethem.

Whenan individual is onawaiting list, theymaynot have access to HIV-related medications. Or,theymayhaveaccessthroughothermechanisms,but these are often unstable. Some individualson waiting lists can get medications throughother health programs within their state, orthrough pharmaceutical assistance programs(PAPs). PAPs, however, require people to applyoften, sometimes as frequently as every month,and separate applications must be sent to themanufacturer of each medication needed. Forsomeoneonamultipledrugregimen,thisprocesscanbequitecumbersomeandmaynotprovidethefull range of drugs necessary for optimal clinicaloutcomes.

Todate,nostatehaseliminatedcurrentclientsfromitsADAPwhenfacedwiththeneedtoimplementawaitinglistfornewapplicants.Nevertheless,stateswithwaiting listsarefacedwithmanychallenges,suchas:howtomonitorthoseonwaitinglists;howtohelp thoseonwaiting lists accessprescriptiondrugsthroughotherprograms,ifavailable;whethercriteria should be developed to bring people offwaiting lists into services or whether new clientsshould be accommodated on a first come, first

serve basis; and what kinds of future decisionscouldbemadetoreduceoreliminatetheneedforwaiting lists,while leastcompromisingaccess forallclients.

Inadditiontowaitinglists,statesuseavarietyofotherstrategiestocontaincosts,someofwhichmayaffectclient access and services. Occasionally, statesmustimplementcost-containmentmeasuresmultipletimesoverthecourseofayear,dependingontheirfiscalsituationandclientdemand.Statesmayalsoremove a measure when it is no longer needed.Cost-containmentmeasures(otherthanwaitinglists)usedovertimebyADAPshaveincluded:

• Loweringfinancialeligibilitycriteria;

• Limitingand/orreducingADAPformularies;

• Limitingaccessforaparticulardrug(s),including institutingadrug-specificwaitinglist;

• Institutingcost-sharingrequirementsforclients;

• Institutingmonthlyorannual limitsonpercapita expenditures.

Itisimportanttonotethatsomeofthesemeasuresmay be used by ADAPs to ensure efficient use offundsandsupportappropriateclinicalmanagementofpatientsonanongoingbasis,andthereforetheymaybeconsideredstandardprogrammanagementpolicies.

RecentfactorshavecombinedtoeasesomeofthepressureonADAPs,includingthePresident’sADAPInitiative (PAI),MedicarePartD,state-level fundingcontributions, pharmaceutical manufacturer drugrebates, and increased ADAP Supplemental DrugTreatment Grant funding. For the first time in thetracking of the program, waiting lists were nearlyeliminatedandsomeADAPsremovedexistingcost-containmentmeasures.However,thisreliefwasnotfeltequallyacrossthecountryandasmallnumberofADAPsneededtoimplementnewprogramlimitationstomanagecosts. ◗

ADAP WAiTiNg liSTS AND OTHER COST-CONTAiNMENT MEASuRES

10

• All ADAPs were in compliance with the new minimum formulary requirement which, at the time of data collection, applied to the four longer-standing antiretroviral drug classes—NRTIs, NNRTIs, protease inhibitors, and fusion inhibitors. In addition, although still within the grace period, most ADAPs had already added the new CCR5 antagonist (44 ADAPs) and integrase inhibitor (43 ADAPs) to their formularies.

• The majority of ADAPs (29) cover every approved antiretroviral in each of the six drug classes.

• All ADAPs also cover the one available multi-class combination product on their formulary.

• The minimum formulary requirement led South Dakota to add protease inhibitors and fusion inhibitors to its formulary for the first time and, although only required to add one protease inhibitor under the law, the state added all 10 approved medications in this class. Three additional states added fusion inhibitors (Alaska, Idaho, and North Dakota) as well.

• Thirty-nine ADAPs cover 15 or more of the 29 drugs highly recommended (“A1”) for the prevention and treatment of opportunistic infections, including six that cover all 29 (Alabama, Alaska, Massachusetts, New Hampshire, New Jersey, and Oregon). Thirteen ADAPs cover less than 15 of these medications. One ADAP does not include any medications for OIs or other HIV-related conditions on its formulary, and only covers antiretrovirals (Louisiana). It is important to note that ADAPs may cover fewer than the full set of highly recommended OI medications because they cover equivalent medications, also highly recommended, on their formularies or have other state-level programs that can provide these medications.

• Hepatitis A, B, and C infections are important considerations for people with HIV/AIDS, and ADAPs play an important role in the provision of treatment for the hepatitis C virus (HCV) and vaccines for hepatitis A and B viruses (see Chart 21 and Table XIII).

– In June 2007, 22 ADAPs covered treatment for HCV on their formularies, down from 25 in 2006. HCV is classified as an HIV-related opportunistic infection, due to the relatively high co-infection rate of HIV and HCV.18,22 Currently, no national funding infrastructure exists to provide treatment to those infected only with HCV, and state and local resources for such treatment vary greatly. Without HCV treatment programs, most of the burden for treating co-infected patients has fallen on ADAPs and other Ryan White programs. Across ADAPs, utilization of HCV treatment is low. The reason most commonly cited by ADAPs is that clients perceive

the treatment to be too difficult. A secondary reason is the lack of client interest and the lack of providers to prescribe treatment.

– 28 ADAPs cover hepatitis A and B vaccines, which are recommended for those at high risk for and living with HIV.23

WAITING LISTS ANd OTHER COST-CONTAINMENT MEASURES/MANAGEMENT POLICIES Waiting Lists

ADAP waiting lists have been documented since the Monitoring Project began tracking ADAPs in 1996, with detailed trend analysis beginning in 2002. At that time 1,108 individuals in seven ADAPs were on waiting lists for ADAP medications. Since then, a total of 20 different ADAPs have instituted a waiting list at some point with the largest number of clients on waiting lists reported at 1,629 in May 2004.

• In September 2007, and for the first time since tracking ADAPs, no ADAPs had client waiting lists. By March 2008, one state (Montana) had a waiting list in place (with three people on the waiting list), compared to four states with a combined total of 571 people on waiting lists in March 2007. This decrease was the result of several factors, including the President’s ADAP Initiative (PAI), which provided short-term, targeted relief; increased state funding for ADAPs in some states and growing revenue from drug rebates; continued implementation of Medicare Part D; and, for those states with particular ADAP capacity limitations, increased ADAP supplemental funding. These factors contributed to the ability of states to move clients off waiting lists and into their programs (see Charts 22 and 23 and Table XIV).

• The size of waiting lists has fluctuated within and across states over time. The number of people on waiting lists reached its peak in mid-2004. Based on bi-monthly surveys conducted between July 2002 and March 2008 (37 surveys overall):

– There was only one period (September 2007) when there were no ADAPs reporting waiting lists.

– 20 ADAPs reported having a waiting list in place at some point over the entire period.

– The highest number of states reporting a waiting list in any given period was 11.

– 12 ADAPs had waiting lists in 10 or more of the survey periods.

– The number of people on waiting lists ranged from a low of one to a high of 1,629 (the average was 653). The highest number of individuals on any one state’s waiting list was 891 (North Carolina);

��

the lowest was one (Alaska, Idaho, Montana,andWestVirginia). NorthCarolinaalsohad thehighestaveragenumberofpeopleon itswaitinglist over the period (337), followed by SouthCarolina (320). The lowest average was four inGuamandWyoming.

• When states have had to use waiting lists, theygenerally report working with pharmaceuticalassistanceprograms(PAPs)tohelpthoseonwaitinglists access medications where possible. Theseprograms,however,arenotmeant tobepermanentsources of drug access and they require people toapplyoften,sometimesasfrequentlyaseverymonth,andtoapplytoeachdrugmanufacturerseparately.

Other Cost-Containment Measures and Management Policies

Whilewaiting listshavealwaysbeen themostvisiblerepresentationofunmetneedforADAPservices,thereareotherwaysinwhichADAPshavesoughttocontrolcostsormanageresourceconstraints.Theseincludereducingorlimitingformularies,establishingenrollmentcapsonparticulardrugs,institutingpatientcost-sharingonmedicationswhenitwaspreviouslynotrequired,orlimitingthenumberofprescriptionspermonth.Aswiththewaitinglisttrend,fewerADAPsreportedinstitutingsuchmeasuresandmaintainingthemthroughtheendofFY2007comparedwithlastyear’sreport(three,not

includingthestatewithawaitinglist,asofMarch2008comparedtoeightintheprioryear),andsevenADAPseliminatedanexistingcost-containmentmeasure (seeChart24).It isimportanttonotethatthesemeasuresare also used by ADAPs to ensure efficient use offundsandsupportappropriateclinicalmanagementofpatients(seeChart25andTableXV).

ADAP BuDgET

The national ADAP budget reached $1.43 billion inFY 2007, an increase of three percent ($42 million)overFY2006(forpurposesofdetermining theoverallADAP budget, federal, state, and drug rebate fundsare aggregated). Since FY 1996, the budget hasgrownmorethanseven-fold.WhiletheADAPearmarkcontinuestorepresentthelargestshareofthenationalADAPbudget, drug rebateshavebecome thebiggestdriverofbudgetgrowthandonlydrugrebatesandADAPsupplementalfundingincreasedoverthelastperiod;allotherfundingsourcesdeclined(seeCharts26–36andTablesXVI–XVIII):

• ADAP earmark funding,11 specifically appropriatedby Congress each year for ADAPs, has risen fromone-quarterofthebudgetinFY1996,theyearitwascreated,to54%inFY2007.Forthefirsttimesincetheearmarkwascreated,however,fundingavailablefrom itdecreasedslightly (byonepercent)betweenFY 2006 and FY 2007 (the ADAP supplemental, alegislatedset-asideoftheearmark,isaccountedforseparatelybelow)(seeCharts29and31andTablesXVIandXVIII).

• While ADAP Supplemental Drug Treatment GrantsaccountedforonlythreepercentoftheoverallADAPbudget(asonly16statesreceivedawards),theygrewmorethanfour-foldbetweenFY2006andFY2007andwereoneofonly two fundingsources that increasedovertheperiod.Theyaccountedforupto18%ofADAPbudgets in thestatesthatreceivedthis funding. TheoverallsupplementalamountismandatedbylawtobefivepercentoftheCongressionallyappropriatedADAPearmark,anincreasefromthreepercentinthepreviousauthorizationperiod—thisincreasedpercentage,whichresulted in increased supplemental grant funding forthe first time, was by design, intended by CongresstohelpredistributefundstoADAPswithmorelimitedformularies, lower income eligibility thresholds, andthose that had cost-containment measures in place.In addition, Ryan White Reauthorization changedthestatematchingrequirement for theSupplementalDrug Treatment Grants, permitting a waiver of therequirement if other Part B matching requirementshavebeenmet(ifapplicable)andpotentiallyproviding

Part B ADAPEarmark

$775,320,700(54%)

Part B ADAP Supplemental$39,477,300

(3%)

Part B Base$24,583,999

(2%)

State Contribution$294,071,393

(21%)

Part A Contribution$12,265,657

(1%)

Other State or Federal$19,640,632

(1%)

Drug Rebates$262,551,285

(18%)

Total = $1.43 Billion

National ADAP Budget, by Source, Fy 2007

Note: 5� ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, and Northern Mariana Islands did not report FY 2007 data, but their federal ADAP earmark and supplemental awards were known and incorporated. The total FY 2007 budget includes federal, state, and drug rebate dollars. Cost recovery funds, with the exception of drug rebate dollars, are not included in the total budget. See Table XVI.

�2

additionalincentivesforeligiblestatestoseekfunding(threenewstatesreceiveditinFY2007)(seeCharts29and32andTablesXVIandXVIII).

• RyanWhitePartBbasefunding,formula-basedfundingallocatedtostates(otherthanthatearmarkedforADAP)representedjusttwopercentofthenationalADAPbudgetin FY 2007; states are not required to allocate thesefundstoADAPs.PartAfundingrepresentedonepercentoftheADAPbudgetinFY2007;thesefunds,whichareallocatedtometropolitanjurisdictions,aredistributedbythesejurisdictionsbasedonlocally-determinedprioritiesandarenotrequiredtobeallocatedtoADAPs.PartBbaseandPartAfundsweretheonlytwofundingsourcesinthenationalADAPbudgetthatwerelessinFY2007thaninFY1996(seeCharts29,33,and34andTablesXVIandXVIII).[Note:The2006ReauthorizationcreatedtwotiersofPartAjurisdictions,eligiblemetropolitanareas(EMAs)andtransitionalgrantareas(TGAs).TobeeligibleasanEMA,metropolitanareasmusthaveageneralpopulationexceeding500,000anddocumentationof2,000ormoreactual AIDS cases reported in the previous five years.TGAsarethoseareasdocumenting1,000–1,999AIDScasesinthelastfiveyears.InFY2007,therewere22EMAsand34TGAs fundedunderPartAof theRyanWhiteProgram(seeChart41andTableXXIII).]

• State funding (general revenue support) continuedtoaccount for thesecond largestshareof theADAPbudget,althoughitdecreasedbyfourpercentbetweenFY 2006 and FY 2007, the first decrease since FY1996. States are not required to provide funding totheirADAPs(exceptinlimitedcases),althoughmanyhave historically done so either over a sustainedperiodoftimeoratcriticaljuncturestoaddressgapsinfunding.Suchfundingis,forthemostpart,dependentonindividualstatedecisionsandbudgets;evenwherestatesarerequiredtoprovideamatchoffederalPartBRyanWhitebasefunds,theyarenotrequiredtoputthis funding toward ADAP. In the case of the ADAPsupplemental,wherestatesarerequiredtoprovideastatematch(orapplyforawaiverofthisrequirementif they have met their Part B match, if applicable),suchfundingrepresentsarelativelysmallshare($35million,or11%,inFY2007)ofstatefundingforADAPs(seeCharts29and35andTablesXVIandXVIII).

• An increasingly critical component of the ADAP budgetis drug rebates, which drove the overall budget growthbetweenFY2006andFY2007.DrugrebateshaverisenfromsixpercentofthenationalADAPbudgetinFY1996to18%inFY2007,growingmorethan20-fold.Whilenotall ADAPs obtain rebates, drug rebates accounted foraboutone-thirdormoreoftheADAPbudgetin11statesinFY2007.Theriseofdrugrebatesasasourceofrevenueisanimportantdevelopmentthatisinpartduetotheneed

for states to seek additional funding as client demandcontinues,andtothegrowingsophisticationofstatesandNASTAD’sADAPCrisisTaskForce inworking toobtainrebates.Somedrugrebatesaredependentonnegotiationsbyindividualstatesorstatecoalitions,andrebateincreasesareinpartafunctionofrisingdrugexpendituresandprices(sincerebatesarebasedonapercentageofdrugprice).Drugrebates,however,arenotavailabletosomestatesduetotheirtypeofdrugpurchasingsystemand,whileanimportantsourceof revenue forothers,maybevariableandunstable(somearebasedonnegotiationsdeterminedwithpharmaceuticalmanufacturers),maybesubjecttoalag,andcouldrequireintenselaboronthepartofADAPstafftocollect(seeCharts29and36andTablesXVIandXVIII).

• ADAP budget composition varies by region. Forexample, ADAP earmark funding accounts for thelargestshareofthebudgetintheSouth(65%)followedby state contributions (19%) and drug rebates (threepercent). In theNortheast,earmarkfundingaccountsfor52%of thebudget,withdrugrebatesrepresenting26%andstatecontributions17%.ADAPbudgetsintheWestareequallycomprisedofearmarkfunding,statecontributions, and drug rebates, and in the Midwest,63%oftheADAPbudgetisfromearmarkfunding,16%isfromstatecontributionsand15%isfromdrugrebates.NineADAPs in theSouth receivedmost (88%)of theADAPsupplemental fundingavailable. SevenADAPSintheMidwestandWestreceivedtheremaining12%ofADAPsupplementalfunding.NostateintheNortheastreceivedADAPsupplementalfundinginFY2007.

• By definition, all eligible jurisdictions (58 in FY 2007)receive federal ADAP earmark funding based on aformula of living HIV and AIDS cases, but, as notedabove,notallADAPsreceivefundingfromothersources,whichareoftendependentonindividualstateandlocalplanning,policy,and/or legislativedecisions,aswellasresource availability. The breakdown of other sourcesoffundingacrossthecountrywasasfollows(among53ADAPsreportingdata)(seeChart27andTableXVI):

–Part B ADAP Supplemental Treatment Grants: 16ADAPsreceivedfunding(anadditional18werealsoeligiblebutdidnotapply);

–PartBBaseFunds:21ADAPsreceivedfunding,32didnot;

–StateGeneralRevenueSupport:40ADAPsreceivedfunding,13didnot;

–PartAFunds:8ADAPsreceivedfunding,45didnot; –OtherState/FederalFunds:17receivedfunding,36

didnot; –DrugRebates:42ADAPsreceivedfunding,11didnot.

• Additionally, despite a three percent increase in thenationalADAPbudgetacrossallADAPsbetweenFY

��

2006 and FY 2007, some ADAPs had decreaseseither in their overall budget or for specific fundingstreams. Someof thesedecreaseswere related todecreases in the overall federal funding allocation,federalfundingdistributionchanges,and/orindividualadjustmentsstatesmadetotheirbudgets(seeChart28andTablesXVIIandXVIII):

–Overall Budget: 35 ADAPs had increases or levelfunding,18haddecreases;

–Part B ADAP Earmark funding: 27 ADAPs hadincreases,31haddecreases;

–PartBADAPSupplementalDrugTreatmentGrants:16hadincreases,sevenhaddecreases;

–Part B Base Funds: 17 ADAPs had increases orlevelfunding,12haddecreases;

–State General Revenue Support: 26 ADAPs hadincreasesorlevelfunding,16haddecreases;

–Part A Funds: five ADAPs had increases or levelfunding,ninehaddecreases;

–Drug Rebates: 31 ADAPs had increases or levelfunding,13haddecreases.

• WhilenotcountedasanADAPbudgetcategory (dueto its high variability and significant delays includingsomethataremulti-year),costrecovery,reimbursementfrom third party entities such as private insurers andMedicaid, for medications purchased through ADAP(otherthandrugrebates),represented$25.9millioninFY2007.Privateinsurancerecovery,inwhichanADAPreceives reimbursement from insurance providers,wasthelargestcomponent(68%).CostrecoveryfromMedicaidrepresented26%andothersources,includingmanufacturers’ free product, represented six percent(seeChart37andTableXIX).

DRug PuRCHASiNg MODElS AND iNSuRANCE COVERAgE ARRANgEMENTS

Drug Purchasing Models

• Thefederal340BDrugDiscountProgram,authorizedundertheVeteransHealthCareActof1992,enablesADAPs topurchasedrugsat or below the statutorilydefined 340B ceiling price.24 Participation in theprogram is not mandatory, yet all ADAPs participate(seeChart38andTableXX).

–ADAPs may purchase drugs either at a lowernegotiated price directly from wholesalers or throughretail pharmacy networks and then apply to drugmanufacturersforrebates.AsofJune2007,29ADAPsreported purchasing directly; 24 reported purchasingthroughapharmacynetworkandthenseekingrebates.

–Direct purchase ADAPs can also choose toparticipate in theHRSAPrimeVendorProgram,24

which was created to negotiate pharmaceuticalpricingbelow the340Bprice. The“primevendor”is an entity that negotiates with manufacturerson behalf of a group of purchasers, in this case340B-coveredentities,toachievesub-340Bprices.Twelveofthe29ADAPsthatpurchasedirectlyfromwholesalersparticipateintheHRSAPrimeVendorProgram.

–Although the District of Columbia participates inthe340Bprogram, itpurchases themajorityof itsdrugsthroughtheDepartmentofDefense,allowingit to access the Federal Ceiling Price, a lowerprice only available to certain federal purchasers.Several other states that participate in the 340Bprogramalsohavestatelawsregardingnegotiationprocessesthatresultinlowerprices.

–NASTAD’sADAPCrisisTaskForcenegotiatesdirectlywithmanufacturersforpharmaceuticalpricingbelowthe340Bpriceonbehalf of both rebateand directpurchase ADAPs. When such agreements arereached,theyareprovidedtoallstates.

ADAP CRiSiS TASK FORCE

TheADAPCrisisTaskForcewasformedbyagroupofstateAIDSDirectorsandADAPCoordinatorsinDecember 2002 to address resource constraintswithin ADAPs. NASTAD serves as the conveningorganization for the Task Force, which originallyconsistedof10representativesofthelargestADAPprograms. Beginning in March 2003, the TaskForcemetwiththeeightcompaniesthatatthetimemanufacturedantiretroviraldrugs.Thegoalof themeetingswastoobtainmulti-yearconcessionsondrugprices,tobeprovidedtoallADAPsacrossthecountry. Agreements were reached with all eightmanufacturerstoprovidesupplementalrebatesanddiscounts (in addition to mandated 340B rebatesanddiscounts),pricefreezes,andfreeproductstoallADAPsnationwide.During2004,theTaskForceexpanded its negotiations to include companiesthatmanufacturehigh-costnon-antiretroviraldrugs.Additional agreements have been obtained sincethenandpreviousagreementswereextendedand/or enhanced. Agreements are currently in placewith14manufacturers.TheTaskForceestimatedsavings of $145 million in FY 2006, and $425millionsinceitsformation.CurrentmembersoftheTask Force include representatives from ADAPsin California, Florida, Michigan, New Jersey, NewYork,NorthCarolina,Texas,andUtah.

TheTaskForcealsocoordinatesitseffortswiththeFairPricingCoalition(acoalitionoforganizationsandindividualsworkingwithpharmaceuticalcompaniesregardinginitialpricingofantiretroviraldrugsforallpayers)andothercommunitypartners. ◗

14

–20ADAPspayPartDpremiums; –25ADAPspayPartDdeductibles; –28ADAPspayPartDco-paymentsforADAPclients

eligibleforPartD; –26 ADAPs pay for all medications on their ADAP

formularies when their Part D clients reach thecoverage gap or “doughnut hole”. This actionmeets the requirement of “payer of last resort”but also provides a safety net for continuing HIVtreatmentaccessforbeneficiaries.

• Inaddition,21ADAPsreportdisenrollingMedicarePartD eligibles who qualify for the full low-income subsidybenefitunderPartD (thoseduallyeligible forMedicaidandMedicareand thosewith incomes less than135%FPL).AsubsetofADAPsalsoreportsdisenrollingPartD eligibles who only qualify for partial subsidies underPart D or no subsidy at all, in which case the ADAPtriestotransitiontheseclientsfromADAPtotheirStatePharmacyAssistanceProgram(SPAP),ifoneisavailable,sinceSPAPcontributionsdocounttowardTrOOP.

ImplementingthePartDbenefitcontinuestobeacomplicatedprocessforsomeADAPs,dependingonavailabilityofPartDprescriptiondrugplansintheirstateandtheirownprograminfrastructureandfinancialresourcesforcoordinatingwiththebenefit.However,thepayeroflastresortmandaterequiresthatADAPsdotheirduediligencetoensureallotherpayersourcesforprescriptiondrugshavebeenexhaustedbeforeanindividualcanbeeligibleforADAPservices.

CHARTS AND TABLES

Charts and tables for each major finding, with dataprovidedbystates,areincludedinthefullreport.State-level data from this report are provided on Kaiser’sStateHealthFacts.orgwebsite:www.statehealthfacts.org/hiv.

REfERENCES AND NoTES

1 Theterm“state” isusedinthisreporttoincludestates,territories,andassociatedjurisdictions.

2 U.S. Census Bureau, Geographic Terms and Definitions, Available at:http://www.census.gov/popest/geographic/(accessedMarch10,2008).

3 Between September 2004 and March 2006. See: The WhiteHouse, “Extending and Improving the Lives of Those Living withHIV/AIDS,”FactSheet,Availableat:http://www.whitehouse.gov/news/releases/2004/06/20040623-1.html(accessedMarch18,2008).

4 Center on Budget and Policy Priorities, http://www.cbpp.org/pubs/sfp.htm(accessedMarch10,2008).

5 Pub.L.101-381;Pub.L.104-146,SEC.2616.[300ff-26].

6 HRSA HIV/AIDS Bureau, http://hab.hrsa.gov/treatmentmodernization(accessedMarch7,2008).

7 BasedonKaiserFamilyFoundationanalysisofdatafromtheCentersforDiseaseControlandPrevention(CDC)andtheJointUnitedNationsProgrammeonHIV/AIDS(UNAIDS).

Insurance Purchasing/Maintenance Programs

• The Ryan White Program allows states to useADAP dollars to purchase health insurance and payinsurancepremiums,co-payments,and/ordeductiblesforindividualseligibleforADAP,providedtheinsurancehas comparable formulary benefits to that of theADAP.25,26StatesareincreasinglyusingADAPfundsfor thispurpose. MoreADAPs thaneverbefore (40)reportedpurchasingormaintaininginsurancein2007,representing$74.5millioninexpendituresinFY2007.In June 2007, 20,960 ADAP clients were served bysuch arrangements—53% higher than in June 2006.June2007expenditureswere63%higherthaninJune2006, although overall 2007 expenditures were 11%lowerthanin2006(seeChart39andTableXXI).

• Thesestrategiesappear tobecosteffective—inJune2007,spendingoninsurancerepresentedanestimated$422 per capita, less than half of per capita drugexpendituresinthatmonth($982).

Coordination with Medicare Part D

The Medicare Prescription Drug, Improvement, andModernizationActof2003(MMA)addedanewoutpatientprescriptiondrugbenefit,PartD,totheMedicareprogrameffective January 1, 2006. It is estimated that 12% ofADAP clients are also Medicare-eligible (representingabout17,000enrolledclients).AsubsetoftheseclientsisduallyeligibleforMedicareandMedicaid.

As the payer of last resort, ADAPs were required byHRSA to ensure that all Medicare Part D-eligibleclients enroll in a Medicare prescription drug plan byMay 15, 2006 (or at least ensure that they are notpaying for any Medicare-covered prescription drugserviceforMedicare-eligibleADAPclients).ADAPsareencouraged to coordinate with Medicare prescriptiondrug plans and, in accordance with state policy, payfordrugplanpremiums,deductibles,coinsurance,andco-payments.25 However, the MMA does not allowADAPfundstobecountedtowardabeneficiary’sTrueOut of Pocket expenses (TrOOP). This means ADAPenrollees whose income defines them as a standardPart D beneficiary (and, therefore, not eligible for lowincomeassistance),mustincurthesecoststhemselveswhen in the coverage gap before they are eligible toreceive catastrophic coverage under their Medicaredrugplan.27

• To meet the federal requirements and maintainappropriate medication coverage for their clients, 30ADAPsreporthavingdevelopedpoliciestocoordinatewiththePartDbenefit(seeChart40andTableXXII).AsofMay2007:

�5

8 HRSA,HIV/AIDSBureau,PersonalCommunication,March15,2005.

9 WhiteHouse,OfficeofManagementandBudget,February2008.

�0 UpuntilthemostrecentreauthorizationofRyanWhite,threepercentoftheADAPearmarkwasset-asidefortheADAPSupplementalDrugTreatmentGrant,grantstostateswithsevereneed.AsofFY2007,thisamountwasincreasedtofivepercent.Seeboxon“AllocationofFederalFundingtoADAPs&StateMatchRequirements”.

METHODOlOgy

Since1996,theNationalADAPMonitoringProject,an initiative of the Kaiser Family Foundation(Kaiser) and the National Alliance of State andTerritorialAIDSDirectors(NASTAD),hassurveyedall jurisdictions receiving federal ADAP earmarkfunding through Ryan White. In FY 2007, 58jurisdictions receivedearmark fundingandall58weresurveyed;53responded.AmericanSamoa,Federated States of Micronesia, Guam, MarshallIslands, and Northern Mariana Islands did notrespond; these jurisdictions represent less thanone percent of estimated living HIV and AIDScases.*

The annual survey requests data and otherprograminformationforaone-monthperiod(June),the current fiscal year, and for other periods asspecified.Afterthesurveyisdistributed,NASTADconductsextensivefollow-uptoensurecompletionbyasmanyADAPsaspossible.Datausedinthisreport are from June 2007 and FY 2007, unlessotherwise noted. Supplemental data collection isconductedincertainareastoobtainmorecurrentdata,including:waitinglists,othercost-containmentmeasures,andformularycomposition.

All data reflect the status of ADAPs as reportedby survey respondents; however, it is importanttonote thatsomeprogram informationmayhavechangedbetweendatacollectionandthisreport’srelease.Duetodifferencesindatacollectionandavailability across ADAPs, some are not able torespondtoallsurveyquestions.Wheretrenddataare presented, only states that provided data inrelevant periods are included. In some cases,ADAPshaveprovidedrevisedprogramdata fromprioryearsandthesereviseddataareincorporatedwhere possible. Therefore, data from prior yearreports may not be comparable for assessingtrends. It isalso important tonote thatdata fromaone-monthsnapshotmaybesubjecttoone-timeonlyeventsorchangesthatcouldinturnappeartoimpacttrends;thesearenotedwhereinformationis available. Data issues specific to a particularjurisdiction are provided on relevant charts andtables. ◗

*CDC,“PersonsLivingwithHIV/AIDSorAIDS,byGeographicAreaandRyanWhiteCAREActEligibleMetropolitanAreaofResidence,December2004”,HIV/AIDS Surveillance Supplemental Report 2006;12(No. 1). Available at:http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006supp_vol12no3/table1.htm.

�� Congress earmarks a specific amount of Part B funds to ADAP eachyear.ToadheretootherprovisionsoftheRyanWhiteProgram,however,theamountavailable todistribute tostatesmayvary from thatoriginalearmark.FivepercentoftheADAPearmarkisremovedtofundADAPsupplementalgrantsandremainingearmarkfundsmayfurtherfluctuateduetoapplicableholdharmlessrequirements.Forexample,inFY2007,Congress appropriated $789.5 million to the ADAP earmark, of which$39.5millionwasusedforADAPsupplementalgrants.Inordertomeetholdharmlessrequirements,HRSAthenaddedapproximately$25millionofPartBbasefundstoapplicablestateADAPearmarkawards.

�2 SomeofthesefundsmustbeprovidedtoADAPs,duetostatematchingfundrequirements.Seeboxon“AllocationofFederalFundingtoADAPs&StateMatchRequirements”.

�� Fundingforentitlementprograms,suchasMedicaidandMedicare,generallychanges(increasesordecreases)basedonthenumberofpeopleeligibletoenrollintheseprogramsandthecostsofprovidingthemcare.

�4 ThisestimateisbasedonannualizingJune2007drugexpenditures.ItisimportanttonotethatJune2007expendituresmaynotberepresentativeofmonthlyexpendituresoverall.

�5 There may be some duplication in the amount reported for drugexpenditures and the amount reported for insurance purchasing/maintenance because some ADAPs are unable to disaggregateco-paymentsintothesetwocategories.

�6 FDA,“DrugsUsedintheTreatmentofHIVInfection”,Availableat:http://www.fda.gov/oashi/aids/virals.html(accessedMarch7,2008).

�7 CDC, “Guidelines for the Prevention of Opportunistic Infections in PersonsInfectedwithHumanImmunodeficiencyVirus.”MMWR2002;51(No.RR08):1-46.Availableat:http://www.aidsinfo.nih.gov/(accessedMarch7,2008).

�8 CDC,“TreatingOpportunisticInfectionsAmongHIV-InfectedAdultsandAdolescents.” MMWR 2004; 53(No. RR15):1-112. Available at: http://www.aidsinfo.nih.gov/(accessedMarch7,2008).

�9 Whilemulti-classcombinationproductsarenotconsideredauniqueclassof drugs, the costs for these drugs were considered separately in thisreport(inthe2007 National ADAP Monitoring Project Annual ReporttheywereincludedintheNRTIclass).Theperprescriptioncostisdifficulttocompare,sincetheoneapprovedmulti-classcombinationproductincludesthreedifferentdrugs(twoNRTIsandoneNNRTI),andcanappearhigherincostthanitactuallyisifcomparedtosingleclassproducts.

20 HRSA’sHIV/AIDSBureaurequiresthatwhenanewdrugcomestothemarketandisapprovedbytheFDA,ADAPsdonothavetoaddthedrugto their formularies (tobecompliantwith thenewminimumformularyrequirement) until the DHHS “Guidelines for the Use of AntiretroviralAgentsinHIV-1-InfectedAdultsandAdolescents”havebeenrevisedtoincorporatethedrug.Oncetherevisedguidelinesarereleased,ADAPshave90daystoofficiallyaddthenewdrugtotheirformularies.

2� ProvidinganyFDA-approvedHIV-relatedprescriptiondrug.

22 CDC, Frequently Asked Questions and Answers About Coinfectionwith HIV and Hepatitis C Virus. Available at http://www.cdc.gov/hiv/resources/qa/HIV-HCV_Coinfection.htm(accessedMarch7,2008).

2� CDC, “Sexually Transmitted Diseases Treatment Guidelines, 2006,”MMWR,Vol.55,September2006.

24 HRSA,PharmacyServicesSupportCenter,“Whatisthe340BProgram?”Availableat:http://pssc.aphanet.org/about/whatisthe340b.htm(accessedMarch7,2008).

25 HRSA,HIV/AIDSBureau,PolicyNotice99-01, “TheUseof theRyanWhiteCAREActTitleIIADAPFundstoPurchaseHealthInsurance.”

26 HRSA,HIV/AIDSBureau,DSSProgramPolicyGuidanceNo.2,“AllowableUsesofFundsforDiscretelyDefinedCategoriesofServices,”FormerlyPolicyNo.97-02,FirstIssued:February1,1997,June1,2000.

27 HRSA, HIV/AIDS Bureau, “Medicare Prescription Drug Benefit andCARE Act Grantees.” Available at: http://www.hrsa.gov/medicare/hiv/about.htm(accessedMarch7,2008).

16

Mat

rix o

f Key

ADA

P Hi

ghlig

hts

Stat

e/Te

rrito

ry

Fina

ncia

l Elig

ibili

ty a

s %

of

FPL

(GR

= Gr

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Inco

me;

NE

T =

Net I

ncom

e),

Dece

mbe

r 31,

200

7

Tota

l FY

2007

Bud

get *

FY 2

007

St

ate

Cont

ribut

ion

FY 2

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Stat

e Co

ntrib

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n

as %

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Bud

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200

7

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Serv

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ne 2

007

Dr

ug E

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Fill

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200

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Per C

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g Ex

pend

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s

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ama

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$16,

973,

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R$6

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——

——

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518

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7

Arka

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500%

GR

$4,2

45,3

10$0

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5$7

29,4

6083

9$2

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Calif

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a40

0% G

R$2

88,1

06,2

87$9

0,56

5,00

031

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,939

$22,

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75,8

69$1

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Colo

rado

400%

GR

$14,

407,

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$4,1

81,2

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462,

341

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ectic

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war

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244

$85,

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911

$349

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rict o

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rate

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ates

of M

icro

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a—

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——

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gia

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GR

$45,

869,

313

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Guam

—$9

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4—

——

——

—

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aii

400%

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88$4

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pshi

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472

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sey

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17

Mat

rix o

f Key

ADA

P Hi

ghlig

hts

(con

tinue

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Stat

e/Te

rrito

ry

Fina

ncia

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me;

NE

T =

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7

Tota

l FY

2007

Bud

get *

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St

ate

Cont

ribut

ion

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e Co

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7

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——

——

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314

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779

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13,9

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,342

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55,9

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472

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127

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.S.)

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inia**

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574,

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1

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t Virg

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101,

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$100

,147

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344,

600

$981

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*The

tota

l FY

2007

bud

get i

nclu

des

fede

ral,

stat

e, a

nd d

rug

reba

te d

olla

rs.

Cost

reco

very

fund

s, w

ith th

e ex

cept

ion

of d

rug

reba

te d

olla

rs, a

re n

ot in

clud

ed in

the

tota

l bud

get.

**Vi

rgin

ia h

as a

n FP

L of

333

% in

Nor

ther

n Vi

rgin

ia a

nd 3

00%

FPL

in a

ll ot

her p

arts

of t

he s

tate

.

Note

: Th

e nu

mbe

r of A

DAPs

repo

rting

dat

a fo

r eac

h ca

tego

ry a

bove

var

ies.

See

Tab

les

I, II,

III,

IV, X

I, an

d XV

I for

add

ition

al d

etai

l. A

das

h (—

) ind

icat

es n

o da

ta a

vaila

ble

from

the

ADAP

. A

zero

($0)

indi

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The National Alliance of State and Territorial AIDS Directors444 North Capitol Street, NW, Suite 339, Washington, DC 20001Phone: 202.434.8090 Fax: 202.434.8092 www.NASTAD.org

The Henry J. Kaiser Family FoundationHeadquarters2400 Sand Hill Road, Menlo Park, CA 94025 Phone: 650.854.9400 Fax: 650.854.4800

Washington Offices and Barbara Jordan Conference Center1330 G Street, NW, Washington, DC 20005Phone: 202.347.5270 Fax: 202.347.5274www.kff.org

The Kaiser Family Foundation is a non-profit, private operating foundation dedicated to providing information and analysis on health care issues to policymakers, the media, the health care community, and the general public. The Foundation is not associated with Kaiser Permanente or Kaiser Industries.

Additional copies of this publication (#7746) are available on the Kaiser Family Foundation’s website at www.kff.org and www.NASTAD.org.