AIDS Action Weekly Update Special Edition

History of ADAP

Program's Struggle to Keep Apace With the Domestic Epidemic

Today, ADAP is a pharmaceutical assistance program serving the uninsured and underinsured. The program is an "earmark" -- funds set aside for a specific use within a grant -- contained in Title II of the Ryan White CARE Act. Funded mostly by federal funds, along with some state dollars (depending on the state), ADAP programs are administered by the states. Each state has its own eligibility criteria which clients must meet in order to enroll and receive benefits from the program. ADAP has its roots in the AZT Assistance Program, which began in 1987 when Congress appropriated funding for individual states to help them purchase AZT for people living with HIV. AZT was the first and, at that time, the only, drug approved by the federal Food and Drug Administration (FDA) for treatment of HIV infection. Congress appropriated $30 million, which was given to the state health departments with the instruction that they were to use the money specifically for the purchase and distribution of AZT. It was left to the individual states to determine who would be eligible for the program.

Over the next several years, new HIV drugs were approved for use by the FDA, and the state AZT Assistance Programs began to use their funding for the purchase of medications other than AZT. However, no legal change was made to the programs until 1990, when Congress incorporated the drug assistance program into the Ryan White CARE Act -- the first piece of legislation designed to comprehensively address the care and treatment needs of people living with HIV who might not otherwise have access to necessary medical care and support services. The AZT Assistance Program was incorporated into Title II of the CARE Act which provides funding to the states and became known as the AIDS Dug Assistance Program (ADAP). The legislation maintained the same level of discretion established by the AZT program by allowing each individual state to determine who would be eligible for assistance through the program.

Initially, ADAP did not receive a specific earmark (designated amount of funding) within Title II, but rather it was funded by the Health Resources and Services Administration (HRSA) out of the amount allocated for Title II. In the first year, Congress appropriated $87.831 million for Title II of the CARE Act.

As written, the CARE Act requires the legislation to be reauthorized by Congress every five years. In 1996 it was reauthorized for the first time. Beginning in fiscal year (FY) 1996, Congress began earmarking funding within Title II specifically for ADAP, a practice that has continued to this day. In FY 1996, Congress appropriated $52 million for ADAP -- out of a total appropriation of $260.847 million for Title II.

Since FY 1996, ADAP has grown to be a larger and larger share of the total appropriation for Title II. Between FY 1996 and FY 1997 alone, the ADAP earmark grew from $52 million to $167 million -- more than tripling the funding for state ADAPs. During this same period the total Title II appropriation increased from $260.847 million to $416.954 million -- an increase of 60 percent. Thus, the proportion of Title II funding earmarked for ADAPs grew from 20% to 40%. Since that time, funding for the ADAP earmark has continued to grow dramatically -- to the point where the majority of dollars for Title II now go directly to funding ADAPs rather than to the main Title II grant process.

There are several reasons why funding for ADAP has increased at such a dramatic rate since 1996. First and foremost was the introduction of antiretroviral drugs (ARVs) and combination therapy (the use of more than one HIV medication simultaneously) in 1996. This breakthrough in HIV treatment led to an increase both in the number of drugs available, and in the number of medications each patient was required to take. Not surprisingly, this development led to a noticeable rise in the costs associated with HIV treatment, which in turn placed a larger burden on state ADAPs. In addition, these advances in treatment have led to people living longer with HIV, and consequently, they are depending on federally funded programs like ADAP for longer and longer periods of time. With new HIV infection rates estimated at over 40,000 a year and death rates declining, ADAPs are forced to manage increasing numbers of clients, and they are in continual need of more resources to meet the growing demand.

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