Although funding for resistance testing is up for debate, almost all doctors who work with indigent patients can agree on one thing: Texas's program that pays for the HIV drugs of uninsured people is in a financial crisis.
ADAP, the AIDS Drug Assistance Program, is a federal program funded primarily through the Ryan White CARE Act, a bill passed in 1990 that pays for and supports services for indigent HIV-positive people. On the state level, ADAP is known as the Texas HIV Medication Program, and it's run through the state's health department. Federal funding constitutes a little more than 80 percent of the program's budget, with the state making up the remainder. The program pays for the extremely expensive drugs people need to stay alive and fight the virus.
But the federal government recently announced that funding for ADAP programs would not increase for the next fiscal year. In a letter to concerned supporters, the bureau chief of Texas's HIV and STD prevention program, Dr. Celine Hanson, announced that the HIV medication program will need an estimated $12 million in 2004 and $16 million in 2005.
"We are going to have to do something," says Dr. Natalie Vanek, who sits on the medication program's advisory board. "There's no doubt it's going to be really ugly."
While the U.S. Health and Human Services Commission would not elaborate on why funding was frozen at the federal level -- it would only confirm the freeze -- activists say many programs suffered after September 11. The ADAP Working Group, a coalition of community-based organizations and biotechnology and pharmaceutical research companies, is projecting an increase of $202 million needed nationwide for fiscal year 2003. Some states, such as North Carolina, already have developed waiting lists for people needing drugs -- those in need must wait for someone to either die or gain insurance through an employer before they can be accepted into the program.
Since its formation in 1987, the Texas HIV Medication Program has provided medications to more than 28,000 Texans, and the program approves more than 163,000 orders for drugs each year. In 2001, it spent $50 million on drugs for more than 11,000 HIV-positive people.
But because of the pressing new need, Houston doctors and activists are worried that the state program will be forced to cut back its spending and limit care. Joel Martinez of The Center for AIDS worries that the medication program will be able to pay for only drugs that attack the virus -- and won't be able to pay for drugs needed for the secondary infections that often crop up when someone is HIV-positive. Dr. Shannon Schrader agrees, adding that his main concern is that newer drugs on the horizon won't be covered at all.
"People on the board are going to have to decide, are there some medications we're not going to cover?" he says. "And that may limit some standard drugs that every other state can cover but Texas can't."
Doctors and activists are also worried that eligibility criteria for patients may change, meaning those who make too much money but lack private insurance will be left in the lurch.
"If you make $35,000" -- but don't have insurance -- "and you don't qualify for ADAP, and you spend $20,000 a year on meds, it becomes a real problem," says Martinez.
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In essence, the program's success has caused some of its failure, says Hanson. Because of the expensive drugs, patients are enjoying longer life spans. But as more people live longer, the need for drugs increases and the expenditures of the program skyrocket. The current budget is a far cry from that of the late '80s, when the program supplied only $1 million worth of AZT, one of the few HIV drugs available at the time.
Hanson stresses that the state program is going to do everything within its power to make up the budget deficit without resorting to cutting care, although she acknowledges that re-examining eligibility criteria is a last resort. First, Hanson says the Texas program will look at how it could become more internally efficient, for example, by instituting cheaper bulk purchasing.
"The standard of care is very clear," says Hanson. "We definitely do not want to provide haphazard care."
There is a bit of good news. In March, the CEO of Pfizer announced that because of the current ADAP budget crisis, the company would freeze the price of Viracept (one of the best-selling protease inhibitors) to state ADAPs for two years. Doctors and activists are now hoping that other drug companies will do the same.