New Study Yields Insights to Women Living with HIV/AIDS, and Viral Suppression

By: Ranier Simons, ADAP Blog Guest Contributor

The goal of HIV antiretroviral therapy (ART) is viral suppression. Viral suppression is reducing the level of HIV in the blood to an undetectable status. Viral suppression is achieved through strict adherence to antiretroviral therapy (ART) regimens in their various forms. Insufficient adherence can result in increased viral loads or even virological drug resistance. As advances in ART continue, it is essential to determine the level of adherence considered sufficient for viral suppression. In a perfect world, all people living with HIV/AIDS would have 100 percent adherence to treatment regimens, meaning that they never missed a dose. That is not realistic. Thus, consensus in medical science views 95% as a high level of adherence. Even 95% adherence is not achievable for many people living with HIV/AIDS (PLWHA). Because data show that viral suppression can be achieved with adherence of less than 95% using newer medications, scientists are investigating the levels of adherence required for this outcome. A recent Canadian study examined viral suppression and treatment adherence among women, taking into account the unique characteristics of many women’s lived experiences (Mokaddam et al., 2025).

Photo Source: HIVinfo | NIH

Presently, ART is lifelong. Thus, effective treatment requires consistent and ongoing adherence. Women living with HIV/AIDS (WLWHA) have unique social, biological, and other categories of lived experience that result in unique challenges to ART adherence (Ogden et al., 2004). Canadian researchers performed a longitudinal study of WLWHA because 2020 data showed women lagged behind men concerning the Joint United Nations Programme on HIV/AIDS target for HIV care. The target is 95-95-95, meaning 95% of all PLWHA should be aware of their status, 95% of those diagnosed should be on effective therapy, and 95% of those on ART should have viral suppression (Mokaddam et al., 2025). PLWHA Data from 2020 shows men at target levels of 90%–87%–96% and women at 88%–85%–90% (Mokaddam et al., 2025). 

The Canadian study utilized data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), a community-based, prospective cohort study. The CHIWOS study was conducted in three waves from 2013 to 2018. The recent Canadian study executed a longitudinal analysis of self-reported survey data, including socioeconomic data, health history including HIV and ART, substance abuse, and even history of violence and abuse (Mokaddam et al., 2025). The researchers specifically included subjects only if they reported utilizing a regimen consisting of an antiretroviral backbone with a third agent. The ‘backbone’ consists of two nucleoside reverse transcriptase inhibitors (NRTIs). The backbone is then combined with a third medication chosen from several classes, including non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), or integrase strand transfer inhibitors (INSTIs) (HIV.Gov, n.d.). The researchers made this distinction as a standard for inclusion to rule out other forms of ART that may be prescribed due to previous drug resistance or other drug interactions and conditions to lower the possibility of confounding factors affecting adherence.

Photo Source: HIV.gov

The cross-sectional analysis of the third wave of participants revealed that overall, 95.5% reported viral suppression, and 76.2% of participants had an ART adherence level of ≥ 95% (Mokaddam et al., 2025). Of those reporting ≥95% adherence, 97% of those achieved viral suppression. Other levels of reported adherence were associated with different viral suppression percentages. Respondents who reported 85-89% adherence had a viral suppression of 78.6%, those with 75-79% adherence had a viral suppression of 75%, and those with less than 65% reported a viral suppression of 76.5% (Mokaddam et al., 2025). Those reporting 90-94% adherence to ART had a viral suppression level of 97.2%, similar to that of those with ≥95% adherence. There were no differences in the odds of participants reporting viral suppression across the various medications used as a third agent to the ART backbone. Approximately 27.2% were on a first-generation INSTI, 34.0% on a second-generation INSTI, 22.9% on a NNRTI, and 15.9% were on a PI (Mokaddam et al., 2025). 

This Canadian study suggests that the odds of achieving viral suppression with adherence rates of 90% or less are significantly lower than those with adherence rates of 95% or higher. Several studies have indicated that viral suppression can be achieved with adherence levels of 75% to 80%. Interestingly, the study observed an increase in the utilization of INSTIs as a third agent, specifically dolutegravir, over the course of the waves between 2013 and 2018 (Mokaddam et al., 2025). The use of dolutegravir increased the odds of virologic suppression (VS) across varying levels of adherence.

WLWHA have unique issues to deal with that affect their ability to maintain treatment adherence. Medication access, living situations, women-specific health conditions, and many other factors influence the ability to engage in care. It is imperative to continue exploring the impact of their lived experience on their ability to maintain adherence, coupled with the development of ART that is more forgiving in terms of the levels of adherence required to maintain viral suppression. This data is vital for women as well as PLWHA as a whole.

[1] Mokaddam, M., Kronfli, N., Sheehan, N. L., Reyes, A. G., Dubuc, D., Loutfy, M., Kaida, A., & De Pokomandy, A. (2025). Antiretroviral therapy use, self‐reported adherence, and viral suppression among women living with HIV in Canada. HIV Medicine. https://doi.org/10.1111/hiv.70034. Retrieved from https://onlinelibrary.wiley.com/doi/10.1111/hiv.70034

[2] NIH Office of AIDS Research (HIV.Gov). (n.d.). HIV/AIDS Glossary: Backbone. Retrieved from https://clinicalinfo.hiv.gov/en/glossary/backbone

[3] Ogden, L., Ogden, J., Mthembu, P., & Williamson, N. (2004). Impact of HIV on women internationally. Emerging infectious diseases, 10(11), 2032–2033. https://doi.org/10.3201/eid1011.040624_01. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3329028/

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.   

United States' HIV Viral Suppression Complemented by State AIDS Drug Assistance Programs

By: Ranier Simons, ADAP Blog Guest Contributor

Population health decisions should always be evidence-based and informed by quality data. State AIDS Drug Assistance Programs (ADAPs), funded by the Ryan White HIV/AIDS Program (RWHAP), provide access to HIV antiretrovirals and other related prescription medications to low-income people living with HIV/AIDS (PLWHA) who are uninsured or underinsured. They also offer other support services that bolster PLWHA’s ability to manage HIV care. Without regard to its inherent value, the Trump Administration's FY2026 budget proposal calls for cuts to the RWHAP, which could adversely affect patients served by ADAPs. A recent study of longitudinal data proves that ADAPs are efficacious and valuable, deserving of more funding, not less (McManus, 2025). 

Photo Source: MedRxIV

A recent study, led by Dr. Kathleen McManus of the University of Virginia School of Medicine, evaluates how ADAPs have contributed to the United States' viral suppression rates from 2015 to 2022. The findings show that ADAPs are effective and their viral suppression outcomes are better than those of PLWHA, who do not receive ADAP-funded services. 

The retrospective longitudinal study explored ADAP participants’ viral suppression (VS) and viral load (VL) data compared to the PLWHA overall population from 2015 to 2022. The state-level data covered all 50 states and the District of Columbia, sourced from the National Alliance of State and Territorial AIDS Directors (NASTAD) National RWHAP Part B and ADAP Monitoring Project Annual Reports and the Centers of Disease Control and Prevention’s (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus (McManus, 2025). All jurisdictions for each year of the study were considered, only including data for a jurisdiction when the NASTAD and CDC data for any given year were both complete. Establishing set guidelines for data inclusion strengthened the validity of the findings.

Photo Source: NASTAD

Over the study period, there were some years where various jurisdictions were not included due to missing data. Overall, 81.9% to 96.4% of the population of PLWHA were included. From 2015 to 2022, the estimated number of PLWHA in the U.S. grew from 942,988 to 1,092,023. The number of ADAP clients from the overall population for each year ranged from 146,879 to 220,839, or 65.5% to 96.9%, respectively (McManus, 2025). 

The VS rate for PLWHA overall ranged from 60% to 66.3%. However, the VS rate for non-ADAP participants ranged from 53.2% to 59.4% compared to 81.2% to 91.4% for ADAP clients. This indicates that viral suppression was significantly higher among those served by state ADAPs. This finding is significant given that for the entire study period, ADAP clients were underrepresented among those eligible for assessment (McManus, 2025). In other words, the proportion of PLWHA ADAP clients overall was always higher than the proportion eligible for VS assessment. Additionally, for all the study years, the proportion of PLWHA who were ADAP clients was greater than the proportion of PLWHA who were ADAP clients with detectable VL. Notably, in 2020 and 2022, the proportion of ADAP clients was only 5.7%, although ADAP clients comprised 23.9% and 21.0%, respectively, for both years (McManus, 2025).

Consistently, ADAP clients comprised one-third (~33%) of all virally suppressed PLWHA nationwide while representing only 21.0% to 24.4% of the total PLWHA population (McManus, 2025). This data illuminates that ADAPs result in higher VS rates than the VS rates of the general population of PLWHA. The cost of HIV antiretroviral medications is not decreasing (McCann et. al, 2020). Moreover, PLWHAs live longer; thus, there is an increasing demand for assistance from ADAPs (McManus et al., 2013). It is not in the best interest of public health nor fiscal responsibility to cut funding to ADAP programs.

Photo Source: HRSA

It would be wiser to increase funding and establish policies that expand and innovate using RWHAP and ADAP funds. Viral suppression increases with ADAP-supported health insurance (McManus et. al, 2019). Supporting expanded ADAP enrollment efforts in addition to ADAP-covered premiums would expand access compared to the costs of providing medication directly for those without any insurance. Cutting RWHAP funds and subsequently ADAP funding would result in the loss of medication and care access for many PLWHA. Disruptions in medication and care access would decrease VS rates and potentially increase transmission rates and poor health outcomes. One CDC study showed that 63% of new HIV transmissions resulted from 34% of PLWHA who were aware of their status but were not virally suppressed (Li et. al, 2016). 

Achieving viral suppression is the most effective way to prevent HIV transmission. “Undetectable = Untransmittable” (U=U) is one of the most essential tenets of HIV treatment and prevention. U=U is possible because of the lifesaving and life-changing medications that ADAPs can provide. Federal funding for ADAPs has remained flat for years, especially for southern states (Nunn, 2014). Cutting funding would be detrimental to state ADAPs across the board. The study, headed by Dr. McManus, should be a data-rich wake-up call for policymakers aiming to reduce funding.

[1] Li, Z., Purcell, D., Sansom, S., Hayes, D., Hall, H. (2016). Vital Signs: HIV Transmission Along the Continuum of Care - United States. MMWR Morb Mortal Wkly Rep. 2019;68(11):267-272. doi:10.15585/mmwr.mm6811e1.  

[2] McCann, N., Horn, T., Hyle, E., Walensky, R. (2020, February 3).HIV Antiretroviral Therapy Costs in the United States, 2012-2018. JAMA Intern Med. 2020;180(4):601–603. doi:10.1001/jamainternmed.2019.7108. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2759735#:~:text=School%2C%20Boston%2C%20Massachusetts-,JAMA%20Intern%20Med.,3

[3] McManus, K., Christensen, B., Nagraj, V., Furl, R., Yerkes, L., Swindells, S., Weissman, S., Rhodes, A., Targonski, P., Rogawski McQuade, E., & Dillingham, R. (2019). Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans’ Association With Viral Suppression. Clinical Infectious Diseases, 71(10), 2572–2580. https://doi.org/10.1093/cid/ciz1123. Retrieved from https://academic.oup.com/cid/article/71/10/2572/5627781

[4] McManus, K., Engelhard, C., & Dillingham, R. (2013). Current challenges to the United States' AIDS drug assistance program and possible implications of the Affordable Care Act. AIDS research and treatment, 2013, 350169. https://doi.org/10.1155/2013/350169. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3614023/#:~:text=The%20demand%20for%20ADAP%20support,goals%3B%20and%20the%20recession%20continues.

[5] McManus, K., Killelea, A., Rogers, E., Liu, F., Horn, T., Steen, A., Keim-Malpass, J., Hamp, A., & Rogawski McQuade, E. (2025). State AIDS Drug Assistance Programs’ Contribution to the United States’ Viral Suppression, 2015-2022. https://doi.org/10.1101/2025.04.04.25325288. Retrieved from https://www.medrxiv.org/content/10.1101/2025.04.04.25325288v1.full.pdf

[6] Nunn, A. (2014, May). The Southern Epidemic: Are the South’s cultural, political and societal barriers making it difficult for public health programs, such as the AIDS Drug Assistance Programs,  to function effectively in this region? Retrieved from https://www.adapadvocacy.org/pdf-docs/2014_aaa_WP_The_Southern_Epidemic_05-15-14.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

NASTAD Releases 2025 Monitoring Project Annual Report

By: Ranier Simons, ADAP Blog Guest Contributor

The National Alliance of State and Territorial AIDS Directors (NASTAD) has released its 2025 National RWHAP Part B ADAP Monitoring Project Annual Report. This is the 28th year of the report, which documents key trends, challenges, and triumphs of state and territorial AIDS Drug Assistance Programs (ADAPs). The report is based on longitudinal data acquired through survey responses. The data covers fiscal year 2023 (FY2023) and calendar year 2023 (CY2023). Of the 58 surveyed jurisdictions that received ADAP earmark funding, 49 provided data. No fiscal or programmatic data were received from Alabama, Montana, West Virginia, the U.S. Virgin Islands, or the Pacific Island Jurisdictions. Limited programmatic data were received from Alaska and South Dakota.

Photo Source: NASTAD

Key findings from this year’s report include:

• Ryan White Part B program funding remained flat. Congressional appropriations for RWHAP Part B in FY2023 was $1.3 billion, with $899.7 million awarded explicitly to ADAP from HRSA. This was the same level of funding as in FY2022.
• Pharmaceutical rebates accounted for the largest share of the overall FY2023 ADAP budget, at 50%. Federal ADAP earmark funding constituted 31%
• The total number of clients enrolled, the number of new clients enrolled, and total number of clients served increased from FY2022. There were 4.7%, 15%, and 4% increases, respectively. 
• Out of the top ten states with the highest number of ADAP clients served, Florida was first serving 29,883 clients, and California was second serving 28,123 clients.
• Of all ADAP clients surveyed from responding jurisdictions during CY2023, 41% had incomes at or below 100% of the federal poverty level (FPL). The majority of ADAP clients, 66%, have incomes at or below 200% FPL.
• In CY2022, 42%, less than half of clients served were people of color, with the majority identifying as Black/African American. In CY2023, 38% of ADAP clients served were Black/African American, compared to 46% in CY2018. Conversely, the proportion of White ADAP clients increased to 54% in CY2023 from 40% in CY2018. Hispanic/Latinx clients comprised 33% of CY2023 clients served compared to 21% in CY2018.
• Biktarvy constituted the majority of ADAP antiretroviral drug expenditures

Photo Source: NASTAD

Discussion

One of the primary goals of Ending the HIV Epidemic in the U.S. (EHE) is viral suppression (Centers for Disease Control and Prevention [CDC], 2024, Mar 20). Of the 47 jurisdictions that provided data, 85% of ADAP clients served in CY2023 reported viral suppression. Comparatively, out of 47 reporting programs in CY2014, 63% reported viral suppression, and out of 53 reporting programs in CY2018, 80% reported viral suppression. These increasing numbers are evidence that ADAP programs are effective and worthwhile public health expenditures. Moreover, CY2023 ADAP client viral suppression is vastly higher than the overall percentage of all people in the U.S. living with diagnosed HIV reporting viral suppression in 2022, which was only 65%. (Centers for Disease Control and Prevention [CDC], 2024, Dec 12).

Regarding funding, some state ADAPs are concerned about the prospect of major reductions in federal funding to state Medicaid programs as part of FY2025 Congressional budget processes. This would fiscally adversely affect ADAPs since federal funding reductions would likely not be bolstered by any increased state investment into the Medicaid program. Thus, ADAPs would have to spend more to help those who may lose Medicaid coverage or be unable to transition to Medicaid if there is a loss of expansion.

Moreover, ADAPs provide full-pay medication assistance as well as ADAP-funded insurance programs for which clients' premiums, deductibles, and cost-sharing are paid. In CY2022, ADAPs provided insurance support for 128,418 clients, spending $698 million with an average cost per enrollee of $5,272; in CY2023, ADAPs spent $745 million on 101,502 clients with an average cost of $7344. Total and per-client expenditures were markedly higher in CY2023, although fewer people were served. According to the report there were also 44,033 ADAP clients served who were enrolled in Medicare (Table 18). It is possible to qualify for Medicare and ADAP with ADAP paying for patient cost-sharing of Medicare Part D prescription drugs that ADAPs cover. The changing landscape of insurance assistance proves that more funding is needed, not less.

Photo Source: NASTAD

 Geographically, the annual report reveals a shift in viral suppression trends. The states with less than 80% of ADAP clients with <200 copies/ml viral loads are primarily concentrated in the Midwest (Chart 8). Seven EHE jurisdictions are in the U.S.: Cook County, Illinois; Marion County, Indiana; Wayne County, Michigan; the entire state of Missouri; and Cuyahoga, Franklin, and Hamilton Counties in Ohio (AETC. 2023). This would indicate that research needs to be done to uncover what caused the shift from the lower levels of viral suppression among ADAP clients in the South to ADAP clients in the Midwest.

The 2025 National RWHAP Part B ADAP Monitoring Project Annual Report contains a wide range of data in its pages, tables, and charts. The report is encouraging, proving that the RWHAP program effectively achieves beneficial health outcomes for the clients it serves. It is also an alert to challenges and a forecast of how ADAPs may need to adjust and innovate to survive.

[1] AIDS Education and Training Center (2023, August 4). AETCs and the Ending the HIV Epidemic Initiative. Retrieved from https://aidsetc.org/ehe

[2] Centers for Disease Control and Prevention (2024, March 20). Ending the HIV Epidemic in the US Goals. Retrieved from https://www.cdc.gov/ehe/php/about/goals.html

[3] Centers for Disease Control and Prevention (2024, December 12). National HIV Progress Report, 2024. Retrieved from https://stacks.cdc.gov/view/cdc/170363

[4] National Alliance of State and Territorial AIDS Directors (2025). 2025 Annual Report: National RWHAP Part B ADAP Monitoring Project annual report. Retrieved from  https://nastad.org/2024-rwhap-part-b-adap-monitoring-report

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Despite Ongoing Chaos, Ryan White Program 2030 Plan Remains Relevant

By: Ranier Simons, ADAP Blog Guest Contributor

In December 2024, Ryan White HIV/AIDS Program (RWHAP) partners received a guidance letter about the Ryan White Program 2030 plan (RWP 2030) from the Health Resources Services Administration (HRSA). The guidance, in the form of a Dear Colleague Letter (DCL) did not include specific policy explanations or detailed implementation instructions, but rathe highlights of directives and unifying paradigms of action. Given the current political climate and the state of flux regarding public health programs and access to public health data on federal agency websites this letter might now be undermined. That said, it is also an acknowledgment of past successes and how they relate to future targets.

(Editor's Note: Some of the links included in the Dear Colleague Letter have already been scrubbed from their websites)

RWP 2030 maintains a focus on an efficacious, high standard of care for those presently benefiting from programs and services through the Ryan White HIV/AIDS Program (RWHAP). The DCL emphasizes the importance of increased efforts to find people living with HIV/AIDS (PLWHA) who are undiagnosed or who have fallen out of the care continuum and bring them into proper care. Data from August of 2024 indicates that 13 percent of the 1.2 million PLWHA in the U.S. are undiagnosed and unaware (HIV.GOV, 2024). That is roughly 156,000 individuals in danger of serious adverse health outcomes due to lack of treatment as well as the potential to unknowingly spread HIV. A combined 40 percent of PLWHA in the U.S. are undiagnosed or diagnosed and not receiving care. 

Great strides have been made regarding viral suppression, and a renewed focus on reaching untreated individuals is the RWP 2030’s aim to increase those numbers. From 2010 to 2023, viral suppression amongst those receiving care under the RWHAP increased from 69.5% to 90.6% (HRSA, 2024). Viral suppression does not happen overnight and is not a permanent self-maintaining endpoint. Reaching viral suppression requires consistent care, and maintaining it requires permanent care.

Source: HIV.gov

The DCL stresses the need for community-driven collaboration and planning. PLWHA live in populations and communities of significant heterogeneity. The RWP 2030 aims to equip people and entities with the resources, capacity-building tools, and training to create the infrastructures needed to meet the specific needs of identified communities. The letter states that success will require “collaboration across sectors, innovation in care delivery, and a commitment to addressing barriers to care” (HRSA, 2024). 

The RWP 2030 framework of leveraging partnerships, focusing interventions, and community engagement is the most effective mindset to have going forward (HRSA, 2024). Presently, there is much uncertainty concerning funding, policy, and potentially adverse effects of political expediency. The DCL reminds RWHAP recipients of the importance of being vigilant with the reevaluation of programs and services to maximize the allocation of efforts to meet locally identified needs. Monitoring is imperative to balance furthering the appropriate care of those already receiving RWHAP services and engaging people new and returning to care.

HRSA plans to release specific guidance and development of tools to support RWHAP recipients in realizing RWP 2030 goals. Some of the education on best practices for outreach, linkage to, and engagement in care is not available as many HIV resources, such as TargetHIV.org, are not available, having been removed from online access by the current administration as of the time of this blog. This fortifies the need for innovative measures of collaboration and the inclusion of non-traditional partnerships to strengthen infrastructures of care. In addition to training and resources, HRSA plans to hold a series of listening sessions in 2025 (HRSA, 2024). The goal is to facilitate exposure to a diverse range of perspectives and experiences associated with navigating the hurdles and pitfalls on the journey of ending the HIV epidemic.

Photo Source: HRSA HIV/AIDS Bureau

Program letters are not only a press statement or documentation for the purposes of public record. HRSA DCLs are a source of information, motivation, hope, and reassurance that RWHAP recipients are supported and are not isolated islands. Reminding entities of their mission and identifying the means to find the help they need is vital for programmatic success. How this plan plays out under the ongoing attacks on public health programs still remains to be seen.

[1] HRSA. (2024, December 20). Dear Colleague Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/rw-program-letter-2030.pdf

[2] HIV.GOV. (2024, August 15). U, S. Statistics. Retrieved from https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics#:~:text=Approximately%201.2%20million%20people%20in,sex%20with%20men%20(MSM)

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

NASTAD Releases 2024 Monitoring Project Annual Report

By: Marcus J. Hopkins, Guest Contributor

The National Alliance of State and Territorial AIDS Directors (NASTAD) has released its 2024 National RWHAP Part B ADAP Monitoring Project Annual Report documenting key trends, challenges, and successes faced by state and territorial AIDS Drug Assistance Programs (ADAPs). This report is developed using information provided to NASTAD by state and territorial ADAPs through information requests, and the 2024 report includes information from 49 states, the District of Columbia, and Puerto Rico. No fiscal or programmatic data were provided by West Virginia, the U.S. Virgin Islands, or the Pacific Island Jurisdictions, including American Samoa, Guam, the Northern Mariana Islands, the Marshall Islands, Palau, and the Federated States of Micronesia.

Key finding from this year’s report include:

• Ryan White Part B programs saw an increase of 1.6% in their Congressional appropriation from Fiscal Year (FY) 2021 to FY2022, from $1.27 billion to $1.29 billion, while ADAP-specific funding provided by the Health Resources Services Administration (HRSA) remained flat at $900m. As NASTAD notes, federal awards alone are not sufficient to meet the needs of Part B programs or their clients;
• Pharmaceutical rebates constituted the largest proportion of the overall ADAP budget for FY2022 at 47%, compared to federal ADAP earmark funding at 34% (Figure 1);

Figure 1 - Total ADAP Budget, By Source, FY1996–FY2022

Photo Source: NASTAD

Note: Rebates are tracked separately from front-end discounts and account for both repayment to ADAP from a manufacturer for a drug expenditure and any additional savings generated. 

Retrieved from National Alliance of State and Territorial AIDS Directors, 2024.

• Reporting ADAPs served a total of 235,615 clients in Calendar Year (CY) 2022, with California serving the most clients at 29,774;
• The percentage of ADAP clients served by ADAP-funded insurance programs increased from 42% in CY2021 to 44% in CY2022, matching for the first time the percentage of ADAP clients served by full-pay medication programs (also 44% in CY2022);
• The age demographics of clients served by ADAPs has shifted slightly as patients age, with clients aged 25-44 increasing from 39% to 40%, those aged 65+ increasing from 12% to 13% from CY2021 to CY2022. Adults aged 45-64 continue to represent the largest percentage of ADAP clients, at 44%, down from 46% in CY2021;
• A majority of the 51 ADAPs that provided information (34, n=67%) have opted to eliminate the six-month recertification requirement. The programs that have left that in place include: Alaska, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Nevada, New Hampshire, North Carolina, Ohio, Oklahoma, Rhode Island, Texas, and Wyoming (NASTAD, 2024);
• 84% of clients served by the ADAPs achieved viral suppression of their HIV (i.e., they achieved viral loads of <200 replicating copies). Clients who received ADAP-funded insurance only or a combination of ADAP-funded insurance and full-pay medication program services were more likely to achieve viral suppression than those who received only full-pay medication program services (Figure 2).

Figure 2 - ADAP Clients Served by Program, by Viral Load, CY2022

Photo Source: NASTAD

Note: Retrieved from NASTAD, 2024.

• 17 of the 51 responding ADAPs reported that less than 80% of their enrolled clients had achieved viral suppression—Alabama, Alaska, Arkansas, Colorado, Connecticut, the District of Columbia, Florida, Georgia, Kentucky, Minnesota, Mississippi, New Jersey, Palau, Pennsylvania, Texas, Vermont, and Wyoming (Figure 3).

Figure 3 - ADAP Viral load Suppression Rate, by Clients Served, CY2022

Photo Source: NASTAD

Note: Retrieved from NASTAD, 2024.

Discussion

State and territorial ADAPs continue to serve as a vital component of HIV care and treatment in the United States, serving nearly a quarter-million Persons Living with HIV/AIDS (PLWHA). While the nation’s PLWHA population, as a whole, suffers from astonishingly low rates of HIV viral suppression, with just 57% of PLWHA achieving viral suppression—one of the lowest rates of viral suppression among comparable high-income countries (Figure 4).

Figure 4 - HIV Viral Suppression Rate in U.S. Lowest Among Comparable High-Income Countries, 2020 or Latest Year

 

Photo Source: KFF

Note: Retrieved from KFF, 2022.

The consistent component of these comparable countries that PLWHA do not enjoy in the United States is that PLWHA enjoy Universal Healthcare coverage in each of them. The AIDS Drug Assistance Program is one of the few programs that provides relatively comprehensive medication coverage for PLWHA, and if the findings in the NASTAD annual report are any indication, the provision of those programmatic services is highly successful in helping patients achieve viral suppression compared to patients who are not beneficiaries of those services.

Each of these nations also provides significantly more permissive and generous social support systems that include relatively easily accessible housing, nutrition, and financial assistance programs, whereas PLWHA in the United States continue to face barriers to viral suppression.

Among adults who reported feeling that they did not receive enough HIV care, nearly all (95.6%) reported experiencing at least one barrier to accessing care and treatment, and nearly two-thirds (62.6%) reported more than one barrier (Dasgupta, Tie, Beer, Fagan, & Weiser, 2021). 50% of respondents in the Dasgupta study indicated having life circumstances that impeded their ability to access care, and 34.5% of those respondents indicated that they faced problems with money or insurance coverage.

It is further interesting that viral suppression rates amongst ADAP recipients in most of the Deep South fall below 80% of ADAP clients. There are several potential factors that may contribute to these lower levels of success among ADAPs, most of which have little to do with the programmatic services, themselves, including (but not limited to):

• The accessibility of HIV care and treatment providers local to patients, including hours of operations, proximity to patients, and the quality of care patients receive;
• A lack of reliable public or private transportation to and from appointments;
• Geographic or weather barriers that may make treatment inaccessible during storm seasons;
• Poverty-driven barriers, including unstable or unaffordable housing, the inability to afford food, or the inability to afford utilities that forces patients to choose between affording to live and affording medications.

Equally interesting are the low suppression rates of ADAP recipients in northeastern states, such as Connecticut, New Jersey, Pennsylvania, and Vermont, while every other surrounding state boasts suppression rates of 80% or higher, with Connecticut and Vermont surrounded by states boasting 90% suppression rates or higher.

It is possible that lower suppression rates in these states may be the result of transportation or accessibility issues, but patients in those states generally experience fewer physical and transportation barriers than those living in the Deep South, which tends to be more rural, have fewer and less accessible public transportation options, and higher patient-to-provider ratios compared to the northeast.

Finally, while it is normal for some jurisdictions to not respond to NASTAD’s annual survey requests, the Pacific Island Jurisdictions seem to almost never respond. An examination of NASTAD reports dating back to 2019 showed that Americans Samoa, the Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, and the Republic of Palau have failed to respond to survey requests every year. While the footprint of ADAP in these territories is relatively small compared to the contiguous states and Puerto Rico, it is still vital that we be able to gain insight into the operations and efficacy of ADAP programs in those jurisdictions.

This issue is not unique to NASTAD. In attempting to gather timely data about programs in those territories, ADAP Advocacy has encountered similar challenges when attempting to access government websites, eligibility requirements, and contact information for the Pacific Island Jurisdictions.

ADAP Advocacy will continue to monitor state and territorial ADAP reports.

References:

Dasgupta, S., Tie, Y., Beer, L. Fagan, J., & Weiser, J. (2021, October). Barriers to HIV care by viral suppression status among US adults with HIV: Findings from the Centers for Disease Control and Prevention Medical monitoring project. Journal of the Association of Nurses in AIDS Care, 32(5): 561-568. https://doi.org/10.1097%2FJNC.0000000000000249

KFF. (2022, June 03). HIV viral suppression rate in U.S. lowest among comparable high-income countries, 2020 or latest year. San Francisco, CA: KFF: HIV/AIDS: Slide. https://www.kff.org/hivaids/slide/hiv-viral-suppression-rate-in-u-s-lowest-among-comparable-high-income-countries-2020-or-latest-year/

National Alliance of State and Territorial AIDS Directors. (2023). 2023 national RWHAP Part B ADAP monitoring project annual report: Section 3: Meeting the need: Ensuring access to essential medicines for People Living with HIV/AIDS. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2023-rwhap-part-b-adap-monitoring-report/section-3

National Alliance of State and Territorial AIDS Directors. (2024). 2024 national RWHAP Part B ADAP monitoring project annual report. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2024-rwhap-part-b-adap-monitoring-report

National Alliance of State and Territorial AIDS Directors. (2024). 2024 national RWHAP Part B ADAP monitoring project annual report: Section 1. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2024-rwhap-part-b-adap-monitoring-report/section1

National Alliance of State and Territorial AIDS Directors. (2024). 2024 national RWHAP Part B ADAP monitoring project annual report: Section 2: Meeting the need: Ensuring access to essential medicines for People Living with HIV/AIDS. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2024-rwhap-part-b-adap-monitoring-report/section2

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Viral Suppression Linked to Access to Timely, Appropriate Care and Treatment

By: Ranier Simons, ADAP Blog Guest Contributor

One of the most critical factors influencing positive health outcomes of people living with HIV/AIDS (PLWHA) is viral suppression. Viral suppression means that the HIV viral load in the blood is so low that it cannot be detected or measured by laboratory tests. Viral suppression is officially defined as having less than 200 copies of HIV per milliliter of blood.[1] Antiretroviral drug therapy (ART) is the current scientifically established most effective way to achieve undetectable viral load status. Studies have routinely shown that viral suppression is a directly associated with PLWHA having access to timely, appropriate care and treatment.

Photo Source: Ideal Healthcare

ART is as vital for prevention as it is for treatment. Maintaining an undetectable viral load means the virus cannot be transmitted to an HIV-negative person through sexual contact.[2] Maintaining undetectable status requires consistent adherence to ART regimens. Unfortunately, many PLWHA face barriers which make medication adherence a challenge. Two significant barriers are affordability and access to ART regimens. 

AIDS Drug Assistance Programs (ADAPs) were created in 1987, and then incorporated under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in 1990 to provide HIV-related prescription drugs to low-income PLWHA who have limited or no prescription drug coverage.[3] The state-administered programs pay for insurance and medical care for 20% of PLWHA in the United States.[4] The Ryan White law states that the purpose of ADAPs is to "provide therapeutics to treat HIV disease or prevent the serious deterioration of health arising from HIV disease in eligible individuals, including measures for the prevention and treatment of opportunistic infections."[5] ADAPs achieve this goal for low-income PLWHA by providing antiretroviral medications and paying for health insurance that covers HIV-related treatments.

To participate in ADAPs, recipients are required to regularly recertify their eligibility for the programs. People are eligible when they meet the criteria of having a documented diagnosis of HIV, fall within the program parameters that define low-income, and meet a particular ADAP’s residency criteria within its service area.[6] Data has shown that many PLWHA struggle to complete the recertification requirements and thus become dis-enrolled. For an in-depth description of the burdensome recertification process, please see a previous ADAP Advocacy blog discussion on the topic here. In an effort to examine the effects of dis-enrollment on viral suppression, a group of researchers performed a study of ADAP clients in Washington state who failed to re-certify and were dis-enrolled.

Photo Source: Washington State

A retrospective cohort study published in May 2023 was performed on 5238 clients in Washington State's ADAP from 2017 to 2019.[4] The researchers used various quantitative and statistical analyses to determine the risk difference of viral suppression before and after dis-enrollment. Several factors, or what are statistically known as unmeasured confounders, overlap in regard to causing dis-enrollment and medication discontinuation. Those confounders include housing instability, poor mental health, binge drinking, and illicit drug use.[4] Stringent statistical efforts were used to isolate the influence of dis-enrollment from those confounders.

A total of 1336 study subjects were dis-enrolled at least once or more than once within the time parameters examined. Results showed that overall, 12 out of every 100 PLWHA lost viral suppression due to dis-enrollment. Disenrollment had an exceedingly harmful effect on those with dual Medicaid/Medicare insurance (22/100) compared to those with private insurance (8/100).[4] Having dual Medicaid/Medicare coverage means that a person has a disability.

During the 2017-2019 window of the cohort study, ADAP clients were required to recertify every six months. Researchers found that those who failed to recertify lost viral suppression almost immediately afterward.[4] Around 83% were virally suppressed before dis-enrollment versus 69% after. This indicates that changes need to be made in the re-certification process to make it less complicated for enrollees to complete and reduce the administrative burden on providers.

In October 2021, Health Resources & Services Administration (HRSA) removed the six-month re-certification requirement. Given that the six-month requirement has deleterious effects on enrollment, it is recommended that ADAPs end the practice of using the six-month default and adopt the newer flexibility in the re-certification policy. The study also noted that Washington state ADAP offers a more extensive breadth of services than most other states. Thus, some Washington state clients who are ADAP enrollees use it for other services and obtain their medications by other means. Therefore, dis-enrollment could have a much more significant impact on viral suppression in other states where every person enrolled in ADAP is dependent on it for their ART.

[1] Centers for Disease Control. (2022, July 21). HIV Treatment as Prevention. Retrieved from https://www.cdc.gov/hiv/risk/art/index.html

[2] World Health Organization. (2018, July 20).Viral suppression for HIV treatment success and prevention of sexual transmission of HIV. Retrieved from  https://www.who.int/news/item/20-07-2018-viral-suppression-for-hiv-treatment-success-and-prevention-of-sexual-transmission-of-hiv

[3] Kaiser Family Foundation. (2017, August 16). AIDS Drug Assistance Programs (ADAPs). Retrieved from https://www.kff.org/hivaids/fact-sheet/aids-drug-assistance-programs/.

[4] Erly SJ, Khosropour CM, Hajat A, Sharma M, Reuer JR, Dombrowski JC (2023) AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017–2019. PLoS ONE 18(5): e0285326. https://doi.org/10.1371/journal.pone.0285326

[5] Penner, M. (2008, October 1). AIDS Drug Assistance Programs: A Lifeline for People With HIV. Retrieved fromhttps://www.thebodypro.com/article/aids-drug-assistance-programs-lifeline-people-hiv#1

[5] Resources Health and Administration Service. (2021, August). Determining Client Eligibility & Payor of Last Resort in the Ryan White HIV/AIDS Program. Report No.: PCN 21–02. Retrieved from https://hab.hrsa.gov/sites

[6] Feller, S. (2023, May 13). Monoclonal antibody speeds time to HIV viral suppression, study finds. Retrieved from https://www.healio.com/news/infectious-disease/20230512/monoclonal-antibody-speeds-time-to-hiv-viral-suppression-study-finds?utm_medium=social&utm_source=twitter&utm_campaign=sociallinks

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

Helping Young Adults Living With HIV To Transition To Adult Care

By: Marcus J. Hopkins, Policy Consultant

Nearly forty years after the start of the HIV/AIDS epidemic, new and better treatment options have led to a number of changes in the how specific patient populations are managed. Over the past decade, increasing attention has been paid to the growing number of aging patients living with HIV – a prospect once thought unfathomable. Another patient population is also increasing – people born or infected with HIV as children who are becoming adults.

According to the most recent estimates, roughly 39,000 youths aged 13-24 were living with HIV in the U.S. in 2016, with approximately 9,000 new infections occurring in this age group in 2014. 80% of those youth were Men who have Sex with Men (MSM) – 55% Black, 23% Latino, and 16% White. These youths are more likely to have complex anti-retroviral therapy ("ART") regimens with underlying multidrug resistances and may face greater obstacles to achieving functional autonomy (Liggett, 2016).

This patient population may face more obstacles to obtaining and achieving adult care and treatment than adults who contract HIV later in life in no small part because those who contract the virus later in life may be better established as functionally autonomous adults. They are likelier to be living on their own and managing to support themselves when they become infected, whereas youths who are transitioning to adulthood, in addition to securing and maintaining HIV treatment and healthcare services, are going to be facing the additional hurdles that come with becoming an adult: becoming independent, finding employment, finding housing, living on their own. These transitions are difficult for all young adults; adding in the additional stress of living with a chronic illness such as HIV can easily hamper this transition.

Photo Source: Huffington Post

Depending upon their state of residence, young patients living with HIV may be engaged in care with pediatric or adolescent HIV/AIDS care providers. Over the course of their care, they may have formed close bonds with their providers, which can make transitioning over to adult care and self-sufficiency more difficult. Additionally, these patients may also have mental health problems or cognitive impairment, which can make adhering to medical care difficult (Tassiopoulos et al, 2019).

In order to ease the transition from pediatric/adolescent care into adult care while maintaining medication adherence and viral suppression, additional efforts should be provided to help these youths develop social connections and support networks outside of clinical settings, as well helping them develop skills to improve self-management of care.

The first part can be accomplished by introducing and/or linking young patients to local or online support groups and networks for youths living with HIV/AIDS. While the scientific evidence that these groups produce concrete positive results for patients is still developing, early reports indicate that patients who engage with and in in-person or online support groups may develop better social connections, have more positive feelings about their treatment and/or care, better engage in the continuum of care, be more adherent to medication regimens, and achieve and/or maintain viral suppression better than patients who do so without a firm support network in place.

The second part – developing skills to improve self-management – can be more difficult to fulfill, and in the inclusion of pediatric social workers may be beneficial in aiding this transition to adult care:

"When adult medical staff questioned patients about their unsuccessful transition, eight reasons were provided compared with 13 reasons when asked by a pediatric social worker: work (12%); transportation (11%); relocation, which resulted in exclusion from the study (9%); no phone access (9%); difficulty dealing with diagnosis (9%); no reported problems (9%); lost insurance (3%); mental health (3%); incarceration (3%); went to a drug treatment facility (3%); family issues (3%); and domestic violence (3%) (Bortz, 2018)."

Many of these issues are directly related to the patients’ ability to become self-sufficient and maintain self-sufficiency, a task difficult enough for every adolescent transitioning into adulthood, but made more complicated by the added pressure of managing HIV/AIDS. Social workers can help these young patients by linking them to social programs (if available) that can help them to receive assistance for phone service, transportation assistance, mental health services, domestic violence issues, and insurance coverage. There may also exist, in some communities, classes and programs that can help people learn to better manage their time, resources, and finances, which can help lead to better self-management of their HIV.

The Ryan White HIV/AIDS Program (RWHAP) served 23,540 youth and young adults aged 13-24, representing 4.4% of the total RWHAP client base (Health Resources and Services Administration (HRSA), 2019). Of these, roughly 780 have unstable housing conditions and 4,602 have no health care coverage (HRSA).

In my own visits to my HIV clinic, my Ryan White Case Manager always asks me if all my needs are being met, if my housing is secure, if I’m having trouble paying bills, or if I need assistance purchasing food. These resources are available through the various parts of the Ryan White Care Act (depending upon the patient’s location). Utilization of these services can help patients with their transition into adult care.

Because this population is relatively new (meaning, higher numbers within the past decade or so), it’s going to be as difficult to transition these patients into the appropriate care settings as it will be to help aging people living with HIV/AIDS to continue managing their disease as they encounter more geriatric conditions.  The Ryan White Program and ADAP, specifically, can serve a vital role in ensuring that these patients continue to have access to the medications and treatment they need to remain healthy at any stage of life.

References:

• Bortz, K. (2018, October 12). Pediatric social workers may be beneficial in transition to adult HIV care. Thorofare, NJ: Healio: Infectious Diseases in Children: Pediatrics: HIV/AIDS. Retrieved from: https://www.healio.com/pediatrics/hiv-aids/news/online/%7Babb84686-700f-4001-9dda-8b7c9e3a41d2%7D/pediatric-social-workers-may-be-beneficial-in-transition-to-adult-hiv-care

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

2017 National ADAP Monitoring Project Annual Report

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

On May 18th, an analysis of the AIDS Drug Assistance Program (ADAP) was released by the National Alliance of State & Territorial AIDS Directors (NASTAD). The 2017 National ADAP Monitoring Project Annual Report tracked state-by-state programmatic changes, emerging trends, and latest available data on the number of clients served, expenditures on prescription drugs, among other things.

The report, which is published annually by NASTAD, provides stakeholders an important snapshot into ADAP-related data, information, and trends. This year's report focuses on several areas, including:

• The importance of the Ryan White Program and ADAP (p. 6)
• What does it take to achieve viral suppression (p. 20)
• Comprehensive care for people living with HIV/AIDS (p. 42)
• Who benefits from services (p. 58) 

Upon releasing the 2017 National ADAP Monitoring Project Annual Report, Murray C. Penner, NASTAD's executive director, stated the following:[1]

"Over the course of time, there have been significant shifts in funding and client needs; ADAPs have worked to meet those needs, however, have sometimes found themselves unable to serve all those in need of services. Lessons have been learned from these circumstances and ADAPs continue to look to identify how they can meet client need and ensure program sustainability. At a time now when ADAPs are documenting program stability, it is imperative that ADAPs look back on how challenges were resolved and look to the future of client needs and determine ways to prepare for the future. ADAPs are at an unprecedented juncture of being able to look to target resources to populations that need them most, to partner with the RWPB to ensure that the whole client’s needs are met, and to identify ways to bolster treatment for individuals’ health."

The 2017 National ADAP Monitoring Project Annual Report overall yielded some very compelling data on the success of the AIDS Drug Assistance Program nationwide in 2016. Some key points are:

• ADAPs provided medications to 225,517 clients in calendar year (CY) 2015, a 235% increase in utilization over the last 10 years;[2]
• The majority (77%) of all clients served by ADAPs in CY2015 were reported as virally suppressed, de ned as having a viral load that is less than or equal to 200 copies/mL;[3]
• Twenty-eight (28) states contribute funding to their ADAP budget.[4]
• Thirty-eight (38) states receive drug rebates to their ADAP budget.[5]
• Overall, nearly 98% of Part B and ADAP budgets are allocated to program services; only 2.2% of Part B and ADAP funding is used to administer the program;[6]
• The majority of ADAPs pay premiums (84%), deductibles (84%) and prescription co-payments/co-insurance (94%) on behalf of eligible clients.[7]
• Forty-three (43) ADAPs reported using funds for insurance purchasing/continuation, representing $161.8 million in estimated expenditures (10% of the ADAP budget at that time) for 30,621 ADAP clients, with an average cost per client of $5,284.[7]

Accompany this year's report are two infographics. NASTAD used one infographic to provide an analysis on ADAPs with the highest rates of viral suppression. Download the infographic, Key Characteristics of Ten ADAPs With Highest Rates of Viral Suppression. The other infographic gives an analysis on the Ryan White Part B and ADAP partnership. Download the infographic, Ryan White Part B and ADAP Partnership to Bolster Health Outcomes.

Photo Source: NASTAD

Several advocates commented on the 2017 National ADAP Monitoring Project Annual Report, providing some important state perspectives. They include:

Ken Bargar, co-chair of the Florida HIV/AIDS Advocacy Network in Florida stated, "FHAAN has made access to our state's ADAP for Floridians a number one priority for many years. As Co Chair, I can tell you that we experience a great relationship with the Florida Department of Health, and we have provided many solutions for improving the program that they have implemented over the years. As a Medicaid non-expansion state, ADAP is crucial for people living with HIV in Florida. The increasing amount of clients receiving premium support for ACA plans has made this program robust and diverse in the ways they get access to HIV medication to our state’s most vulnerable clients. Recently, we were thrilled to see “pharmacy choice” finally became a reality for a section of the programs enrollees."

Eddie Hamilton, executive director of the ADAP Educational Initiative in Ohio, "In terms of transparency and the responsiveness to client’s concerns, Ohio's ADAP has come a long way since the last waiting list era. The ease of access to the program has drastically improved as there are now multiple routes of access (via case management, or direct application)."

Marcus J. Hopkins, an ADAP recipient and HIV/AIDS advocate in West Virginia, summarized, "West Virginia's ADAP is one of only twelve states in which 89% of enrolled clients in 2015 have achieved HIV Viral Loads ≤200. Our state had 1,139 clients in 2015, and only 3 Ryan White-specific clinics, meaning that many clients must travel 60 miles or more in order to reach one of these facilities. Our state is broken up into seven Ryan White regions, with 1 primary case manager contact per region. The small number of clinics serving 55 clinics (not including private Infectious Disease specialists) sometimes creates confusion, as clients living in different regions may have to coordinate between two different case workers. West Virginia's program also offers insurance continuation assistance, providing premium and co-pay assistance for clients enrolled in employer-based or ACA Insurance Marketplace coverage."

Matt Pagnotti, Director of Policy and Advocacy for AIDS Alabama, noted, "Since Alabama has failed to expand Medicaid under the ACA, the state's ADAP has operated as a vital safety net for thousands of people living with HIV in Alabama. Over three fourths of the clients served by Alabama's ADAP earn 133% FPL ($16,040 a year for a single adult) or less, most of whom find themselves in the "Medicaid coverage gap." In addition, roughly 16% of those served by ADAP in Alabama qualify for subsidized health insurance under the ACA marketplace. To assist these clients in overcoming financial barriers to access and create greater coverage completion, Alabama also operates an innovative Insurance Assistance Program that pays for premiums and co-payments."

The ADAP Advocacy Association commends NASTAD for its ongoing efforts to keep stakeholders informed, and engaged on the issues enumerated in this year's National ADAP Monitoring Project. Download a copy of the 2017 National ADAP Monitoring Project Annual Report.

__________

[1] Penner, Murray (2017, May 18); NASTAD Release: 2017 National ADAP Monitoring Project Annual Report; National Alliance of State & Territorial AIDS Directors.

[2] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 60. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.

[3] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 22. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.

[4] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 9. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.

[5] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 9. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.
[6] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 22. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.
[7] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 44. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.
[8] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 43. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.