Ryan White Program Faces Funding Challenges, States Limit Access to HIV Care

The Ryan White HIV/AIDS Program, a critical safety net for people living with HIV, is facing increasing strain due to constrained budgets and rising costs. Several states are responding by implementing cost-containment measures that could limit access to essential care and treatment, potentially reversing progress in the fight against the HIV epidemic.

Federal Funding Lags Behind Growing Needs

Established in 1990, the Ryan White HIV/AIDS Program provides outpatient HIV care, treatment, and support services to individuals without health insurance and those with limited coverage. It serves over half of all people diagnosed with HIV in the United States. However, federal funding has not kept pace with the growing needs of the population.

Since 2005, Ryan White HIV/AIDS Program appropriations, adjusted for inflation, have declined by 31%. In fiscal year 2024, the program received $2.6 billion in funding, including support for the “Ending the HIV Epidemic” (EHE) initiative. Despite this, the program’s funding has largely remained stagnant for over a decade, diminishing its purchasing power.

States Implement Cost-Containment Measures

As federal funding struggles to meet demand, states are increasingly turning to cost-containment measures, including restricting eligibility for programs and limiting the scope of services offered. The National Association of State and Territorial AIDS Directors (NASTAD) reports that 23 states (including Washington, D.C.) have implemented or are considering such measures.

Florida’s Changes to ADAP

Florida has recently announced significant changes to its AIDS Drug Assistance Program (ADAP), which provides HIV treatment and insurance assistance. The state plans to reduce income eligibility from 400% of the federal poverty level (FPL) to 130% FPL, drastically limiting the number of residents who qualify for assistance.

Florida intends to remove Biktarvy, the most widely prescribed antiretroviral medication nationally (accounting for 52% of the U.S. ARV market), from its formulary. The state is also rolling back its insurance assistance program, which could exit individuals with limited affordable healthcare options. These changes have faced legal challenges from advocates, patients, and providers.

Other States Follow Suit

Florida is not alone in implementing cost-containment measures. Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their ADAP programs, albeit to a lesser extent. Other states are exploring options such as reducing formularies, decreasing funding for medical and support services, and implementing stricter recertification requirements.

While no state has yet implemented a waiting list for ADAP services, Arkansas, Louisiana, and New Jersey are considering this as a potential cost-saving measure.

Factors Contributing to Budget Pressures

Several factors are contributing to the financial strain on ADAP programs:

• Increased Client Enrollment: The number of ADAP clients served has increased by 56% from 2007 to 2024, rising from 165,382 to 257,644.
• Rising HIV Drug Costs: The average wholesale price of recommended antiretroviral regimens has increased significantly over the past decade.
• Increased Insurance Premium Costs: The expiration of enhanced Affordable Care Act (ACA) premium tax credits has led to substantial increases in insurance premiums, making coverage less affordable for individuals with HIV.

Potential Consequences and Future Outlook

Limiting access to Ryan White services could have serious consequences, including worsening health outcomes, increased morbidity and mortality, and a potential rise in new HIV infections.

As ADAP programs face ongoing budget pressures, it is crucial to advocate for increased federal funding and explore innovative solutions to ensure that people living with HIV have access to the care and treatment they need. The future of the Ryan White HIV/AIDS Program, and the health of those it serves, depends on sustained investment and a commitment to ending the HIV epidemic.