By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy
The National Alliance of State and Territorial AIDS Directors (NASTAD) has released its annual National Ryan White HIV/AIDS Program (RWHAP) Part B ADAP Monitoring Report. Highlights from the report indicate that, while the program is achieving the goal of helping ADAP recipients suppress their HIV, the failure of governments to adequately fund state programs and those programs’ increasing reliance on drug rebates imperils the lives of those recipients (NASTAD, 2026a).
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| Photo Source: NASTAD |
The 2026 ADAP Monitoring Report includes findings from Fiscal Year 2024 (FY2024) and Calendar Year 2024 (CY2024) and relies on state and territorial ADAPs to respond to NASTAD’s inquiries about their programs to ensure that the information provided therein is as accurate as possible. That said, 2 U.S. states (Mississippi and West Virginia) and 7 territories (American Samoa, the Federated States of Micronesia, Guam, Marshall Islands, the Northern Mariana Islands, the Republic of Palau, and the U.S.).S. Virgin Islands) failed to respond to these inquiries.
What’s Working Well
Viral Suppression
87% of ADAP recipients in FY/CY2024 achieved viral suppression. This is a considerable improvement over the 74% suppression rate in FY/CY2024 and much better than the national suppression rate of 67%.
HIV suppression rates in the United States have consistently lagged behind those of economically comparable nations (Figure 1). Compared to similar nations, the U.S. HIV viral suppression rate tends to fluctuate between 57% and 67%, while other nations range from 72% (Canada) to 92% (United Kingdom). Persons Living with HIV/AIDS (PLWHA) who are enrolled in ADAP have achieved viral suppression rates that allow the U.S. to “compete” with other nations.
The primary difference between the U.S. and other nations is that those nations provide universal healthcare coverage, allowing patients to rest assured that their HIV medications will be covered. Comparatively, PLWHA in the United States must contend with significant barriers to accessing HIV care and treatment due to our nation’s reliance on a for-profit healthcare system that prioritizes profits over health outcomes. The ADAP program has allowed patients similar surety that they will have access to the medications they need to live healthy, productive lives
Figure 1 - HIV Viral Suppression Rate in the U.S. Lowest Among Comparable High-Income Countries
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| Photo Source: KFF |
Whom ADAP Served in FY/CY2024
In CY2024, ADAPs served 257,644 individual clients across 49 reporting jurisdictions, acting as the primary access point for nearly one-quarter (23%) of the 1.13 million people aged 13 years or older living with diagnosed HIV in the United States at the end of 2023.
This represents a 7.5% increase over CY2019 levels, and NASTAD notes that this increase underscores patients’ growing reliance on the program despite the full implementation of the Affordable Care Act (ACA).
In FY/CY2024, 40% of all ADAP program clients earned 100% or less of the Federal Poverty Level (FPL), and 65% earned 200% or less.
Additionally, nearly half of all ADAP clients (43%) are People of Color (POC), with 38% Black, slightly lower than the 40% who were Black in CY2019. 36% of ADAP clients identify as Hispanic/Latine, a significant increase from 28% in CY2019.
Finally, the majority of ADAP clients (55%) were aged 45 or older, with the proportion of clients aged 65 or older increasing from 9% in CY2019 to 14% in CY2024.
NASTAD notes that the continued “greying” of ADAP enrollees will necessitate “…robust coordination between ADAPs and Medicare to ensure seamless coverage for the aging caseload.”
How ADAP Clients Are Served
Because the AIDS Drug Assistance Program is federally funded but state-administered, each state is allowed to determine how it serves ADAP clients. The traditional ADAP program provides full-pay medication coverage for clients, on which 47% rely.
Since the passage of the Affordable Care Act (ACA), however, the Health Resources Services Administration (HRSA) has allowed state ADAPs to use funds to purchase commercial health insurance coverage for ADAP clients and to reimburse those with employer-sponsored insurance coverage. 41% of clients across the United States rely on the ADAP program for said coverage.
Additionally, 12% of clients rely on a combination of full-pay and insurance support to address critical coverage gaps between drug formularies.
Trouble on the Horizon
In addition to the positive impacts ADAPs have had on clients, significant issues loom over state and territorial programs that threaten their solvency and continued effectiveness.
Rising Costs
The most pressing concerns faced by state ADAPs is that healthcare costs have risen exponentially and are likely to continue rising as a result of both Congressional inaction to increase federal funding for RWHAP and the deliberate refusal of Congressional Republicans to extend the enhance premium tax credits implemented by the American Rescue Plan Act of 2021 (ARPA) and extended by the Inflation Reduction Act of 2022 (IRA).
These tax credits were implemented to lower ACA Marketplace premiums for all patients, and Congress’s refusal to extend them resulted in a 21.7% increase in Marketplace premiums for benchmark second-lowest-cost Silver plans and 6%- 7% increases in employer-sponsored insurance premiums (Holahan, O’Brien, & Kennedy, 2025).
These premium increases highlight what many advocates have argued since the passage of the ACA: The ACA was never likely to control insurance costs because no limits were placed on annual premium price increases.
The primary failure of the American healthcare system is its convoluted, fragmented nature, full of special-interest-driven loopholes. The current “market” theory relies not on patients who need care, but rather on what insurers and government payors are willing to pay.
For-profit entities do not, in fact, care whether or not patients can afford the care they need; that’s not their purpose. Their purpose is to generate profits for their companies and their shareholders.
This results in a system where patients have to forego care and potentially die in the richest nation on the planet.
For ADAPs, these increased premiums pose significant threats to annual budgets, which increasingly rely on medication rebates to fill their coffers.
For nearly a decade, federal funding for ADAP has remained largely flat despite rising costs. In fact, federal funding has not accounted for more than 50% of annual ADAP funding since 2008 (Figure 2). Meanwhile, rebates now account for more than 50% of annual ADAP budgets.
Figure 2 - Total ADAP Budget, By Source, FY1996–FY2024
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| Photo Source: NASTAD |
This places ADAPs at significant risk of being unable to continue providing the level of care and services they offer due to a revenue mechanism subject to “…intense market and regulatory volatility.”
What does this phrase mean?
Essentially, rebates rely on two things: high drug list prices and low 340B purchase prices. Under the rebate model, programs purchase medications at full list price and are reimbursed by pharmaceutical manufacturers for the difference between list price and 340B purchase price.
But what happens when price controls, such as those implemented under the Medicare Drug Negotiation Program created by the IRA, are introduced?
The purpose of the Medicare Drug Price Negotiations is to essentially limit what pharmaceutical manufacturers can charge the federal Medicare program for their medications. This means that a drug with an annual Wholesale Acquisition Cost of $36,000 may be forced to sell its medication to Medicare for $16,000 per year, which significantly reduces the total rebate amount that ADAP pharmacies may receive.
This doesn’t just apply to medications that treat HIV, but to every medication eligible for 340B rebates.
The reality is that, if patients get their way, government price controls are all but assured.
73% of patients surveyed in 2023 said that there was not enough government regulation when it comes to limiting the price of prescription drugs, with 67% or more of respondents agreeing with that sentiment across party affiliation (82% of Democrats, 67% of Independents, and 68% of Republicans; Sparks et al., 2024).
This finding wasn’t a one-time fluke; patients have long been in favor of significant increases in government regulations as they relate to controlling prescription drug prices, with 88% of patients being in favor of limiting annual drug price increases to no more than the rate of inflation, 88% of patients being in favor of the government negotiation drug prices for the Medicare program, 78% being in favor of importing drugs from Canada, 72% being in favor of increasing taxes on pharmaceutical companies that refuse to negotiate prices with the federal government, 63% being in favor of increases taxes on companies who drug prices are too high, and 57% being in favor of ending tax breaks given to drug companies for advertising spending.
What this could mean for state ADAPs is that, with increased patient fury at the healthcare industry and systems, in general, elected officials are more likely to begin listening to patients than to industries. Should significant price controls be implemented, the rebate model could collapse, leaving ADAPs facing the loss of 50% or more of their annual operating budgets.
How Are ADAPs Responding
Faced with the various funding hurdles, state and territorial ADAPs are beginning to implement “cost containment” measures (translation: cuts) that will result in significant negative outcomes for the patients who rely upon ADAP for their HIV medications.
These “cost containment” measures include (but are not limited to):
- Decreasing income eligibility requirements so that fewer PLWHA are eligible for benefits
- Delaware eligibility decreased from 500% of the FPL to 350%, effective for all clients as of April 1st, 2026, impacting ~176 patients
- Florida decreased from 400% to 130% of the FPL effective March 1st, 2026, impacting ~16,000 patients
- Kansas decreased from 400% to 250% of the FPL to receive ACA premium assistance, while maintaining the 400% limit for full-pay medication coverage, impacting ~230 patients
- Pennsylvania decreased from 500% to 350% of the FPL effective October 1st, 2026, impacting ~1,592 patients
- Rhode Island decreased from 500% to 400% of the FPL effective March 1st, 2026, impacting ~51 clients
- The following states are considering additional changes to income eligibility:
- Arkansas, Louisiana, New Jersey, Rhode Island, Virginia, & Washington State
- Reducing RWHAP Part B funding for core medical/support services
- Implemented in Arkansas, Connecticut, Delaware, Kansas, Louisiana, Michigan, Pennsylvania, Rhode Island, Virginia, & Wisconsin
- Implementing or reimplementing 6-month recertification requirements
- Implemented in Alaska, Oklahoma, & Rhode Island
- Introducing per-patient expenditure caps
- Implemented in Arizona, Colorado, Delaware, the District of Columbia, & Nevada
- Reducing formulary coverage for both HIV-related and non-HIV-related medications
- Implemented in Arizona, Florida, Louisiana, Michigan, Nevada, & Pennsylvania
- Decreasing, restricting, or eliminating insurance premium assistance
- Implemented in Florida, Michigan, Montana, Oklahoma, & Wisconsin (NASTAD, 2026b)
HIV advocates and activists are also concerned about the potential reintroduction of state ADAP program waitlists, with Arkansas, Louisiana, & New Jersey reporting that they are considering implementing waitlists (NASTAD, 2026b).
The reality of this landscape is that trouble is brewing for RWHAP and the PLWHA who depend upon its various parts and programs to stay alive. ADAP Advocacy will continue to monitor and report on circumstances as they develop.
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.
References:
[1] Holahan, J., O’Brien, C., & Kennedy, N. (2025, December 18). Understanding the Extraordinary Increase in ACA Premiums in 2026. Washington, DC: Urban Institute: Research: Publication. https://www.urban.org/research/publication/understanding-extraordinary-increase-aca-premiums-2026
[2] KFF. (2025, January 24). HIV Viral Suppression Rate in U.S. Lowest Among Comparable High-Income Countries. Washington, DC: KFF: HIV/AIDS. https://www.kff.org/hiv-aids/hiv-viral-suppression-rate-in-u-s-lowest-among-comparable-high-income-countries/
[3] National Alliance of State and Territorial AIDS Directors. (2026a). 2026 National Ryan White HIV/AIDS Program Part B ADAP Monitoring Project Annual Report: Stabilizing the Safety Net: Stewardship and Outcomes in a Volatile Landscape. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2026-rwhap-part-b-adap-monitoring-report
[4] National Alliance of State and Territorial AIDS Directors. (2026b, February 09). NASTAD ADAP Watch - February 2026. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/resources/nastad-adap-watch-february-2026
[5] Sparks, G., Kirzinger, A., Montero, A., Valdes, I., & Hamel, L. (2024, October 04). Public Opinion on Prescription Drugs and Their Prices. Washington, DC: KFF: Health Costs. https://www.kff.org/health-costs/public-opinion-on-prescription-drugs-and-their-prices/
