NASTAD’s National Ryan White HIV/AIDS Program (RWHAP) Part B and AIDS Drug Assistance Program (ADAP) Monitoring Project, including its Annual Report, documents key trends, challenges, and successes faced by public health programs ensuring access to life-saving treatment and services for people living with HIV (PLWH) nationally. In the 22nd year of its history, this 2019 edition of the Annual Report marks the first featuring comprehensive, longitudinal data spanning several domains of the RWHAP Part B program and ADAP, including budget, expenditures, utilization, and client demographics.

The National RWHAP Part B and ADAP Monitoring Survey and the resulting Annual Report reflects a relatively abbreviated snapshot of calendar year 2017 and fiscal year 2018, highlighting those data points that are most dynamic year-to-year, including budgets and expenditures, as well as client utilization and health outcomes (i.e., viral load suppression). As in previous iterations, the Annual Report also aims to illustrate the actual or potential impacts of key policies (e.g., federal/state changes to the Affordable Care Act (ACA) and Medicaid coverage) on RWHAP Part B programs’ and ADAPs’ effectiveness in delivering treatment and key support services for HIV and comorbid conditions that disproportionately impact PLWH.

As sources of care for PLWH who are under-or uninsured via private insurance, Medicaid, Medicare, and other insurers (i.e., “payer of last resort”), RWHAP Part B programs and ADAPs are critical players in ongoing efforts to achieve the goals of the National HIV/AIDS Strategy (NHAS) and jurisdictional ending-the-epidemic (ETE) initiatives. Changes to the broader health care and payer landscape may have significant downstream effects on ETE initiatives as well as RWHAP Part B programs, ADAPs, and the clients they serve.

Overview of the RWHAP Part B Program

RWHAP Part B programs were created under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, passed by Congress, with significant bipartisan support, and signed into law by President George H.W. Bush in 1990. This legislation was enacted to create and sustain a responsive care system that spans the continuum of HIV care: HIV diagnosis; linkage to, and lifelong engagement in, HIV medical care and supportive services; access to safe, effective, and easy-to-use treatment; and durable virologic suppression.

Part B of the RWHAP maintains the infrastructure through which state and territorial health departments are funded to provide core medical and support services to eligible clients. As in other Parts of the RWHAP, Part B is administered by the Health Resources and Services Administration’s HIV/AIDS Bureau (HRSA/HAB). All 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the six U.S. Pacific Territories/Associated Jurisdictions are eligible for Part B program funding. In funding states and territories directly, Congress has empowered jurisdictions to implement and modify equitable systems of care for those who would most benefit in both urban and rural settings.

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Chart 1

Total RWHAP Part B Budget, by Source, FY2017-FY2018

Note: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, and Republic of Palau did not respond. Percentages may not total 100% due to rounding.

The Part B program includes the administration of ADAPs to ensure access to lifesaving treatments for HIV (e.g., antiretroviral (ARV) medications, “A1” opportunistic infection (OI) medications) and comorbid conditions that disproportionately impact PLWH and/or affect the adherence to or effectiveness of ARV treatment. The Drug Reimbursement Program was first implemented in 1987 via Congressional appropriation to provide the newly Food & Drug Administration (FDA)-approved treatment, zidovudine (AZT), to PLWH without private insurance or who were ineligible for Medicaid, Medicare, or other state programs. These state-based programs were absorbed into the then RWHAP Title II program in 1990 and were subsequently changed to “AIDS Drug Assistance Programs” in 1996. Over time, ADAPs have evolved by providing expanded formulary coverage and increasing their capacity in supporting clients via ADAP-funded insurance programs. ADAPs work in concert with the broader Part B program; clients can receive services from either ADAP alone or in combination with other Part B services, depending on their needs and eligibility.

Each jurisdiction’s RWHAP Part B program is administered and delivers services uniquely, reflecting the needs and challenges of their clients and the political and structural landscape in which they exist. Yet every RWHAP Part B program shares a goal of guaranteeing access to treatments and services that bolster clients’ engagement in care, likelihood of durable virologic suppression, and overall wellbeing. RWHAP Part B programs are comprised of the following key components: core medical/support service delivery, including ADAP; quality management (i.e., a series of activities that focus on enhancing the quality of HIV care provided and increasing access to services); and program administration (i.e., administrative, planning and evaluation, salaries, overhead, client eligibility and enrollment, and data system management and reporting).

The breadth of service categories allowable under RWHAP represent a comprehensive and patient-centered approach to serving individuals with a chronic disease who experience complex social and structural barriers and/or comorbid conditions. Core medical services such as Early Intervention Services (EIS), Health Insurance Premium and Cost-Sharing Assistance for Low-Income Individuals, Medical Case Management, Mental Health Services, and Outpatient and Ambulatory Health Services support eligible clients across the HIV-care continuum by bolstering testing, linkage to, and retention in care for HIV and comorbidities. As compared to the general population, RWHAP clients demonstrate higher outcomes across the HIV care continuum; in 2017, 86% of clients receiving RWHAP medical services were virally suppressed. Meanwhile, RWHAP support services (e.g., Housing Services, Medical Transportation Services) undergird these by ensuring adherence to and the effectiveness of clinical care. The array of RWHAP services ensures that public health priorities (e.g., minimizing new infections by optimizing viral load suppression) and individual clients’ overall health and wellness needs are simultaneously addressed.

The National RWHAP Part B Program Budget

RWHAP was last reauthorized in 2009 and the most recent authorization sunset ended on September 30, 2013. In the absence of Congressional action on authorization, the program continues to operate as Congress maintains annual appropriations to the program. Based on a formula and eligibility-based distribution mechanism, RWHAP Part B programs are eligible to receive the following categories of federal funding: Part B Base, Part B Supplemental (if applicable), Part B ADAP Earmark, Part B ADAP Supplemental (if applicable), and ADAP Emergency Relief Funding (if applicable). In FY2018, RWHAP Part B programs (n=59) were Congressionally appropriated a total of $1.4 billion, with $893 million awarded by HRSA to ADAP specifically (i.e., via Part B ADAP Earmark (n=59), Part B ADAP Supplemental (n=6), and ADAP Emergency Relief Funding (n=9)). By comparison, RWHAP Part B programs and ADAPs were awarded $1.4 billion and $896 million in FY2017, representing a -1.3% and -0.6% change for each.

RWHAP Part B programs must use at least 75% of federal RWHAP awards (e.g., Part B Base, Part B Supplemental) to fund core medical services, including ADAP (unless a “75/25 waiver” is approved by HRSA/HAB). RWHAP Part B programs may choose to allocate a portion or all their Part B Base and/or Part B Supplemental to ADAP. For FY2018, 24 RWHAP Part B programs reported having allocated at least some portion of their RWHAP Part B Base and/or Part B Supplemental to ADAP, representing 10% of their overall ADAP budgets. As the largest component to the RWHAP Part B program with the greatest number of clients served (97%), ADAPs represented 74% of the overall Part B budget in FY2018. The proportion of the RWHAP Part B budget used for ADAP ranged from 2% in the American Samoa and the Federated States of Micronesia to 93% in New York. Between 1997 and 2018, the total ADAP budget has grown 458% with an average growth of 9% per year. Yet these awards alone do not meet the needs of RWHAP Part B programs or their clients. Instead, jurisdictions must often use other funding streams to sustain their infrastructure and service delivery.

Additional sources that may be available to RWHAP Part B programs include other federal funding (e.g., carry-over from prior Part B Base or ADAP Earmark awards), state general revenue funding, private donations, and rebates received as part of medication purchasing. RWHAP Part A programs in eligible metropolitan areas may contribute directly-appropriated funds to their Part B counterparts. Such decisions are made locally and reflect an effort between RWHAP Parts A and B programs to avoid duplicating service delivery and to mutually ensure each other’s success in serving the needs of PLWH. Taken together, these additional funding sources make up 51% of the FY2018 RWHAP Part B program and ADAP budgets.

Rebates received in medication purchasing (32%), state contributions (12%), and Part B base (11%) make up the greatest proportions of the overall Part B budget for FY2018. The breakdown of sources of funding for RWHAP Part B programs can be found in the box to the right.