United States General Accounting Office

GAO Report to the Subcommittee on Labor,

Health and Human Services, and

Education, Committee on

Appropriations, U.S. Senate

October 1998 HIV/AIDS DRUGS

Funding Implications

of New Combination

Therapies for Federal

and State Programs

GAO/HEHS-99-2

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-276444 

October 14, 1998

The Honorable Arlen Specter

Chairman

The Honorable Tom Harkin

Ranking Minority Member

Subcommittee on Labor, Health and Human

 Services, and Education

Committee on Appropriations

United States Senate

Recent estimates of the prevalence of HIV infection in the United States

range from 650,000 to 900,000 people.1

 Almost 240,000 of these individuals

are living with AIDS, the end stage of HIV and the leading cause of death

among 25- to 44-year-olds.2

 Since 1996, there have been major

breakthroughs in the fight against HIV and AIDS. New drug therapies, such

as combining protease inhibitors (which inhibit the replication of the

virus) with other drugs, are effective in reducing the amount of virus in

many people with HIV, thereby delaying the onset of AIDS. These therapies

have also been effective in reducing some of the severe immune system

suppression in people with AIDS.

Increased use of combination drug therapies has potential implications for

federal and state budgets, since many HIV and AIDS patients are entitled to

prescription drug assistance under Medicaid or are served by other joint

federal and state programs, such as those authorized under title II of the

Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.

Therefore, you asked us to describe (1) federal and state spending on HIV

and AIDS drug treatment, by major programs, over the last several years;

(2) the estimated number of people with AIDS and HIV on combination drug

therapy who are covered by Medicaid or other publicly funded programs,

and measures that have been taken to stretch the resources in the CARE Act

programs; and (3) the potential impacts of new drug therapies on federal

and state government outlays.

To conduct our work, we interviewed officials at the Department of Health

and Human Services (HHS), including those at the Health Resources and

Services Administration (HRSA) and the Health Care Financing

1

John M. Karon and others, “Prevalence of HIV: Infection in the United States, 1984 to 1992,” Journal of

the American Medical Association, July 10, 1996, and interview with Karon, July 15, 1997.

2

HIV (human immunodeficiency virus) is characterized by a gradual deterioration of the immune

system. As HIV progresses, individuals become particularly vulnerable to illnesses that are typical of

AIDS (acquired immunodeficiency syndrome).

Page 1 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Administration (HCFA). We also analyzed budget information for fiscal

years 1995, 1996, 1997, and 1998. We synthesized data and documents from

a number of sources, including the Centers for Disease Control and

Prevention (CDC) and associations that represent state and industry

providers of HIV and AIDS drugs. We also interviewed officials from states’

AIDS Drug Assistance Programs (ADAP) and consulted with HIV and AIDS

researchers and with officials from pharmaceutical companies that

manufacture HIV and AIDS drugs.

Combination drug therapy is new; as a result, our findings are limited by

the many unknown factors regarding the effects of these drugs. In

addition, federal program eligibility requirements are subject to change.

We conducted our evaluation between November 1996 and June 1998 in

accordance with generally accepted government auditing standards.

Results in Brief While state governments and private payers share in the financing of

medical care for people with HIV and AIDS, the federal government

currently funds more than half the cost of such care. For fiscal year 1998,

estimated federal spending on treatment for individuals with AIDS or HIV is

expected to total over $5 billion, an increase of about 5 percent over fiscal

year 1997. We estimate that a substantial portion of federal spending for

AIDS or HIV medical care—at least one-sixth—is for prescription drugs,

primarily through Medicaid and funding under title II of the CARE Act for

states’ ADAPs.3

 With recent research developments in HIV and AIDS

treatment—especially the new combination drug therapies—the demand

for federal and state funding for HIV and AIDS treatment is expected to

increase. Between 1995 and 1997, the expenditures for HIV- and AIDS-related

drugs more than doubled in the Medicaid and ADAP programs from

$606 million to $1.3 billion—primarily because of the increase in the

percentage of people with HIV and AIDS seeking combination drug therapy,

which costs about $10,000 per patient annually. These increases are

especially apparent in programs funded under the CARE Act.

More than half of the 240,000 people with AIDS in the United States are

estimated to be receiving combination drug therapies that include a

protease inhibitor and other drugs. Of the AIDS patients on Medicaid, we

estimate that at least 67,500 are receiving combination drug therapy in

1998. Data on the number of individuals who are HIV positive but do not

have AIDS are insufficient, so it is difficult to develop reliable estimates of

3

For this report, “state ADAPs” refers to ADAPs in the states, the District of Columbia, and Puerto

Rico.

Page 2 GAO/HEHS-99-2 HIV/AIDS Drugs
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the total number of Medicaid- and ADAP-eligible individuals who would

likely qualify for and seek combination drug therapy. However, some

ADAPs report that a great majority of their clients are receiving

combination therapy in 1998. ADAPs have taken several steps to stretch

available funds and thereby maximize the number of clients they are able

to serve. For example, most ADAPs are purchasing drugs at a discount and

the ADAP programs we reviewed have taken steps to ensure that clients

who are eligible for Medicaid coverage are in fact enrolled in Medicaid.

Nonetheless, some ADAPs have been required to restrict enrollment or limit

benefits for qualifying individuals.

Other factors—such as evolving standards of care, the long-term

effectiveness of current therapies, and new research developments—also

influence projections of the impact of new drug therapies on federal and

state government programs. Although the effect of the demand for the new

combination therapies is difficult to estimate, ADAPs will likely experience

greater financial pressure than Medicaid in caring for individuals with AIDS

or HIV who seek assistance. This is in part because Medicaid primarily

provides coverage for those individuals whose HIV infection has progressed

to AIDS, and there are some indications that Medicaid costs for drug

therapy might be offset by reductions in hospitalizations. In contrast,

ADAPs cover drug costs for both AIDS patients and others who are HIV

positive—a rapidly growing candidate population for drug therapy—and

who have fixed incomes. Since ADAPs only cover drugs, cost offsets are not

likely to occur.

Background The results of research on the prevention and treatment of AIDS—a disease

first identified in the United States in 1981—have only recently begun to

accrue. Over the past 11 years, a number of therapies have been developed

to fight both HIV and its associated infections and cancers. The Food and

Drug Administration (FDA) has approved several dozen drugs for treating

HIV infection or AIDS-related conditions, many of which have only been

made available during the last 2 to 3 years.

In December 1995, FDA approved the first protease inhibitor, saquinavir

(Invirase).4

 Following this, the agency approved three other protease

inhibitors: ritonavir (Norvir), indinavir (Crixivan), and nelfinavir

(Viracept). In November 1997, FDA approved a new formulation of

4

HIV and AIDS treatment has relied on two classes of antiviral drugs: reverse transcriptase inhibitors

and protease inhibitors. Reverse transcriptase inhibitors affect HIV’s ability to combine with the cells it

infects at an early stage of the infection process. Protease inhibitors interrupt virus replication at a

later stage in the life cycle, after cells have been infected.

Page 3 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

saquinavir, Fortovase. Most recently, in September 1998, FDA approved

efavirenz (Sustiva), a drug that requires less frequent dosing and has

milder side effects than other drugs. Because HIV can develop a resistance

to these and other AIDS treatment drugs, several drugs are often combined.

Combination therapy is likely to include three to five drugs, including

reverse transcriptase inhibitors combined with protease inhibitors. For

many patients, combining protease inhibitors with other drugs greatly

reduces the amount of HIV.

Before it was possible to readily measure the amount of virus in patients,

most drug therapies were targeted to patients whose infection had

progressed, as evidenced by a decline in their immune system function or

by the onset of clinical signs and symptoms of HIV. Of the 650,000 to

900,000 people with HIV infection in the United States, the CDC estimates

that about 500,000 of those people know their HIV status; and for almost

240,000 of these individuals, HIV has progressed to AIDS. In June 1997, the

National Institutes of Health (NIH) released standards of clinical care for

HIV and AIDS combination drug therapy.5 The standards recommend that

therapy be initiated as early as possible and that HIV and AIDS drugs be used

in combination rather than individually. Under the treatment guidelines, all

patients with HIV infection are considered to be candidates for the

combination drug therapy, greatly expanding the group requiring

treatment.

New combination therapy standards also call for continuity of therapy and

optimum dosages to suppress HIV replication. According to NIH,

underdosing and lapses in a patient’s therapy regimen greatly increases the

risk of the patient’s developing drug-resistant HIV variants. Optimum

regimens and dosing are under study and continually changing.

Combination therapies of as many as five drugs currently are prescribed.

Aggressive regimens such as these must be coupled with, and are driven

by, results of frequent blood testing to monitor immune system status and

levels of HIV. This focus on early and aggressive treatment, coupled with

NIH’s call for frequent monitoring of HIV-positive individuals, is expected to

result in greater numbers of people seeking combination drug therapy and

possibly more complex and costly drug treatment regimens, and more

treatment-associated costs such as laboratory testing.

5

To date, much of the care of HIV and AIDS has been fairly decentralized; these guidelines are

designed to provide structure to clinical care. For more on these guidelines, see HHS, CDC, Report of

the NIH Panel to Define Principles of Therapy of HIV Infection and Guidelines for the Use of

Antiretroviral Agents in HIV-Infected Adults and Adolescents (Atlanta, Ga.: Apr. 1998).

Page 4 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

The cost of combination therapy—taking into account all federal drug

discount pricing—is estimated to be about $10,000 per patient annually.

While some people with HIV or AIDS are covered by private medical

insurance, many others are either uninsured or have limited prescription

drug coverage and must rely on one or a combination of federal and state

programs and assistance programs offered by manufacturers of HIV and

AIDS treatment drugs.

Federal, State, and Private

Funding Sources for HIV

and AIDS Drug Therapy

The majority of federal assistance for AIDS patients is provided through

Medicaid and programs funded under the CARE Act, which was enacted in

1990 to help alleviate the burdens placed on a public health system

generally unprepared for the AIDS epidemic.6,7 In 1998, Medicaid is

estimated to cover 55 percent of adult AIDS patients and about 90 percent

of pediatric AIDS cases.8

 Applying those percentages to the current number

of AIDS cases, we estimate that at least 108,000 individuals with AIDS are

covered by Medicaid in 1998. The CARE Act provides funding for states’

ADAPs, which rely on federal, state, and local partnerships to provide drug

therapy on an outpatient basis. ADAPs are designed to provide assistance to

those HIV-positive individuals who have no, or limited, private third-party

prescription drug coverage; cannot afford to pay for drugs themselves; and

are ineligible for Medicaid or have limits on the prescription drug benefit

offered by Medicaid. In calendar year 1996, ADAPs served a total of about

80,000 clients nationwide.

Funding for HIV and AIDS drug therapy as well as other treatments is also

provided by other federal sources, including the Departments of Defense

(DOD) and Veterans Affairs (VA). DOD programs currently treat about 5,000

active duty service personnel with HIV or AIDS. In 1996, VA treated more

than 12,000 eligible veterans. While the total number of individuals served

in these programs is much smaller than the number served through

Medicaid and programs funded under the CARE Act, VA is the nation’s

largest provider of direct care for people with HIV and AIDS. In addition, VA

clients could be eligible for care from more than one program.

6

Medicaid is a joint federal and state program that pays for health care services for eligible low-income

individuals.

7

In addition, the Medicare program covers qualified individuals with AIDS. Most who qualify are

disabled and meet criteria for the Social Security Disability Insurance program. However, since

Medicare does not generally cover prescription drugs except for patients who are hospitalized, we did

not focus on this program in our analysis.

8

Interview with John Klemm, HCFA Office of the Actuary, HHS, Aug. 27, 1998.

Page 5 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

The remainder (less than half) of the individuals with AIDS rely on sources

other than ADAPs, VA, DOD, or Medicaid to finance their drug therapy. Some

have private health insurance and others are uninsured and rely on

personal resources and charitable organizations. Uninsured and

underinsured individuals with AIDS tend to rely on a combination of public

and private funding sources. For example, pharmaceutical companies that

manufacture HIV and AIDS drugs have programs to provide limited

temporary assistance to individuals who are financially disadvantaged and

ineligible or waiting for other sources of prescription coverage.9

Eligibility Criteria for HIV

and AIDS Drugs Through

Public Programs

Medicaid enrollees have access to the new drug therapies if prescription

drugs are offered by their state Medicaid program and these drugs are

deemed the appropriate therapy. Medicaid provides health coverage for

certain low-income families, the elderly, and disabled persons. States vary

in their Medicaid eligibility requirements (see app. I). States have

discretion regarding the quantities and duration of use for prescription

drugs, although all FDA-approved drugs must be offered. Historically,

program eligibility has been linked to receipt of cash assistance under a

welfare program, such as Aid to Families With Dependent Children (AFDC)

or the Supplemental Security Income (SSI) program. In recent years, the

program has been expanded to provide health coverage for low-income

children and pregnant women with no ties to welfare. An individual with

AIDS or HIV infection could qualify for Medicaid on the basis of eligibility for

a cash assistance program or alternative eligibility criteria.10 Most adults

with AIDS or HIV infection become eligible for Medicaid by meeting the

disability criteria of the federal SSI program, usually not until they have

developed AIDS and have become too disabled by their disease to work.11

Patients who do not qualify for Medicaid may seek assistance from ADAPs,

which are primarily designed to fill gaps in prescription drug coverage. To

9

Assistance is typically limited to 90 days, after which time patients must reapply for benefits. Patients

may also be required to make copayments for the drugs.

10Under rules adopted since welfare reform, the Medicaid population can be divided into three broad

categories: (1) people whose Medicaid eligibility is primarily based on receipt of cash assistance;

(2) people who do not receive cash assistance; and (3) people who receive cash assistance but could

qualify for Medicaid under an alternative eligibility category such as the so-called Medicaid

“expansion” population—pregnant women, infants, and children born after September 30, 1993. In

addition, states can extend Medicaid coverage to certain categories of individuals with too much

income to receive cash assistance but who are considered medically needy because of their high

medical costs.

11A disabled adult is one who is unable to engage in any substantial gainful activity because of a

medically determined physical or mental impairment that is expected to result in death or that has

lasted (or can be expected to last) at least 12 months.

Page 6 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

qualify for ADAP benefits, they must have a medical need and an income

below a certain amount, which is generally higher than that permitted for

Medicaid. Unlike Medicaid, ADAPs do not require disability as a criterion

for eligibility of HIV-positive adults and thus can cover those who have not

developed AIDS. (For more detail on each state’s financial criteria for

Medicaid and ADAP eligibility, see app. I.)

Recent Federal and

State Spending on HIV

and AIDS Drugs

Through Medicaid and

ADAPs Has Increased

The care of HIV and AIDS patients for all types of treatment, including drugs,

involves a variety of programs funded by the federal government, states,

and private payers, but the largest share of federal funding is through the

Medicaid program. Within these programs, expenditures for drugs have

increased rapidly in recent years and account for most of the growth in the

CARE Act programs.

A Variety of Programs

Provide Funding for HIV

and AIDS Patients

The federal government, states, and private payers all help to finance the

care of HIV and AIDS patients for all types of treatment, including drugs. The

federal portion of Medicaid is the largest share of federal funding;

however, most states match federal Medicaid funds on nearly a one-to-one

ratio.12 Other programs also provide supportive services for low-income

individuals with HIV or AIDS. For example, in fiscal year 1997, about

$133 million was allocated by formula to 53 metropolitan areas and to 27

states for areas outside qualifying cities under the Department of Housing

and Urban Development’s (HUD) Housing Opportunities for People With

AIDS program.13

In fiscal year 1997, total federal spending on medical care, including

inpatient and outpatient services and prescription drugs, for individuals

with AIDS or HIV was estimated at $4.8 billion.14 This amount includes

federal matching payments that HCFA estimates at $1.8 billion for fiscal

year 1997.15 Total federal spending for HIV and AIDS medical care in fiscal

12In fiscal year 1996, states paid 43 percent—$66 billion—of the total Medicaid program costs for all

programs.

13HUD’s Housing Opportunities for People With AIDS program provides grants, allocated by formula,

to states and metropolitan areas with the largest number of cases and incidence of AIDS. HUD also

selects grantees through national competition of projects proposed by state and local governments and

nonprofit organizations. These programs, however, do not provide funding for HIV and AIDS drugs.

14Federal spending on treatment includes funding through HCFA for the Medicaid and Medicare

programs, the CARE Act, VA, Office of Personnel Management, DOD, and the Department of Justice.

15The federal government matched an estimated $1.5 billion in state funds.

Page 7 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

year 1998 is estimated by HHS at $5 billion; the precise amount of Medicaid

spending for HIV- and AIDS-related treatment is not yet known.

Federal Spending for

HIV/AIDS Drugs Has

Increased Rapidly

We estimate that a substantial proportion of federal spending for AIDS or

HIV medical care—at least one-sixth—is for prescription drugs, primarily

through Medicaid and the ADAPs. Between 1995 and 1997, the combined

expenditures in the Medicaid and ADAP programs for HIV- and AIDS-related

drugs more than doubled, rising from $606 million to $1.3 billion. Spending

on drug therapies represented about one-fourth of federal and state

Medicaid spending on HIV- and AIDS-related drugs and exceeded

$950 million in calendar year 1997, up $449 million (or 90 percent) since

1995. Similarly, spending through ADAPs is estimated at $359 million for

fiscal year 1997, up $254 million (or 242 percent) since 1995. (See table 1.)

Much of this increase can be attributed to an increase in the percentage of

people with HIV and AIDS seeking combination drug therapy and the

increased expense of combining drugs as opposed to a single medication.16

Table 1: Recent Federal and State

Spending Estimates for All HIV- and

AIDS-Related Drugs Through Medicaid

and ADAPs

Medicaid ADAP

Dollars in millions

Budget perioda Federal State Total Federal Stateb Total

CY 1995 $258.7 $242.6 $501.3 $70.8 $34.3 $105.1

CY 1996 329.0 308.5 637.5

FY 1996 145.6 69.6 215.2

CY 1997 490.0 460.0 950.0

FY 1997 242.8c 116.2 359.0

Percentage change, 1995-97 89 90 90 243 239 242

Note: Estimates are based on preliminary reports, grant applications, or other estimates.

aMedicaid spending is calculated on a calendar-year basis. After 1995, ADAP spending has been

calculated on a fiscal-year basis.

bThe state share for ADAP takes into account funds generated through cost-saving efforts by

states, including manufacturers’ rebates and strategies that seek reimbursement from third

parties.

cThis number includes $167 million earmarked from title II of the CARE Act plus discretionary

resources committed by grantees and title I contributions.

Source: HCFA.

16The increased cost is not likely related to an increase in people with HIV/AIDS. The estimated

prevalence of HIV in the population has remained relatively stable in the United States since 1990.

Statistical models suggest that each year, roughly the same number of Americans become infected

with HIV as die from AIDS-related illnesses.

Page 8 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Federal ADAP Funding

Accounts for Most CARE

Act Increases

Over the past several years, overall federal funding for the CARE Act has

increased more than 50 percent, from about $760 million in 1996 to about

$1.2 billion in 1998. However, in this 3-year period, increases in funding for

CARE Act services other than ADAPs have been minimal, while ADAP funding

has more than quintupled. (See table 2.)

Table 2: CARE Act Federal Funding

Levels, by Title

Fiscal year

Dollars in millions

Title 1996 1997 1998

I—Assistance to eligible metropolitan areas $392 $450 $465

II—Care services 209 250 258

II—ADAP 52 167 285

IIIb—Early intervention services 57 70 76

IV—Demonstrations and evaluations 29 36 41

V—Special projects and evaluations 19 24 25

Total $758 $997 $1,150

Sources: HHS budget office, Feb. 10, 1997, and Congressional Research Service, Nov. 8, 1997.

States also provide considerable resources to fund ADAPs through the CARE

Act. The fiscal year 1997 state contributions of $98 million represented

almost a doubling of state dollars from fiscal year 1996. However, between

fiscal years 1995 and 1997, the portion of ADAP funding from state dollars

dropped from 31 percent to 25 percent because federal funding grew even

more quickly than state funding. (See app. II for state contributions.)

Certain metropolitan areas that are disproportionately affected by the AIDS

epidemic are eligible to receive funding under title I of the CARE Act for the

delivery of comprehensive HIV and AIDS medical care and support services.

Some of these title I programs make eligible metropolitan area (EMA)

contributions to the state ADAP programs. Between 1995 and 1997, when

direct federal funding for ADAPs under title II increased dramatically, title I

contributions to ADAPs remained flat. EMA contributions totaled

$20.8 million in fiscal year 1995, $25.9 million in fiscal year 1996, and

$24.2 million in fiscal year 1997. There is no requirement that contributions

be made from title I programs to ADAP. (See app. III for a list of title I EMA

contributions to ADAPs, by state.)

In addition, title I pays for HIV/AIDS drugs exclusive of the ADAPs. In general,

EMAs report that these expenditures have risen during this time frame. In

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B-276444 

several cases, the expenditures rose significantly after 1996, which could

reflect the introduction of the protease inhibitors and other new therapies.

However, detailed information on these expenditures is not available.

Current Estimates

Show an Increase in

People Seeking New

AIDS Drugs, Requiring

ADAPs to Take Steps

to Stretch Resources

At least half the people infected with HIV were estimated to have been on

combination therapy in 1997, increasing to over 60 percent of patients in

1998. Developing such estimates by insurance coverage or payer source is

difficult. It is possible to estimate the number of Medicaid beneficiaries

with AIDS who are likely receiving combination therapy. However, given

the lack of data on the number of Medicaid beneficiaries with HIV that has

not yet progressed to AIDS, it is not possible to develop estimates of the

number of these individuals who will seek combination therapies. It

likewise is difficult to estimate the number of individuals who will

ultimately seek ADAP coverage for combination drug therapy because of

the lack of good data on the characteristics of those served. However,

recent experiences show a steadily increasing demand for ADAP services.

ADAPs have taken a number of steps to stretch their limited resources,

including cross-checking program enrollment with Medicaid and obtaining

discounts for drug purchases.

An Increasing Number of

Medicaid Beneficiaries

With AIDS Will Likely Seek

Combination Drug Therapy

Although there are a number of FDA-approved drugs for the treatment of

HIV, at least half of the people with AIDS in the United States are estimated

to be receiving therapies that combine a protease inhibitor with other

drugs. These drugs are also available for individuals who are HIV positive

but do not have AIDS, but data on this population are of insufficient quality

to pinpoint the number of HIV cases receiving combination drug therapy.

Only 30 of the states report HIV status, and the comprehensiveness of the

reporting varies by state. Some of the states without HIV reporting have a

large number of AIDS cases, such as New York and California, suggesting

that many HIV cases are not reported.

On the basis of their clinical experience and research, two AIDS researchers

developed formulas to determine the number of people who might seek

combination drug therapy in 1997 and 1998.17 They estimated that of the

total number of people in the United States with AIDS or who are HIV

positive, 50 percent would be on combination therapy in 1997 and 60 to

17Interview, February 10, 1997, with John Bartlett, Professor of Medicine, and Richard Moore,

Associate Professor, Johns Hopkins University School of Medicine.

Page 10 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

65 percent in 1998.18 They assumed that about 20 percent of people who

try combination therapy will not be able to tolerate the side effects and

will therefore discontinue it. They also assumed that some patients will

choose not to (or cannot because of their lifestyle) take the medication

and that some HIV-positive individuals will be unaware of the infection and

thus will not seek treatment.

We developed estimates of the number of Medicaid beneficiaries with AIDS

who will likely seek combination drug therapy in 1997 and 1998. In 1998,

Medicaid covered an estimated 55 percent of all adult AIDS cases and

90 percent of all pediatric AIDS cases, while in 1997 these percentages were

estimated to be 54 percent for adult cases and 90 percent for pediatric

cases. Medicaid currently covers at least 108,000 AIDS patients and covered

at least 104,000 AIDS patients in 1997. Therefore, using the AIDS researchers’

formulas, we estimate that for the Medicaid beneficiaries with AIDS, at least

52,000 (50 percent of 104,000) would have been on combination therapy in

1997 and at least 67,500 (62.5 percent of 108,000) are on therapy in 1998.19

Given the lack of data on the number of Medicaid beneficiaries with HIV

that has not yet progressed to AIDS, it is not possible to develop estimates

of the number of these individuals who will seek combination therapies.

However, the gender and age distribution of HIV-positive individuals who

do not have AIDS will likely differ from the gender and age distribution of

beneficiaries with AIDS who have qualified for Medicaid on the basis of

disability. This HIV-positive group includes pregnant women, women and

their dependent children, and children in low-income families who

qualified for Medicaid because they met federal and state income and

categorical eligibility requirements. Although they may be asymptomatic,

they could qualify for Medicaid—and thus for coverage of their HIV-related

care—for an extended period of time, depending on their income and

other qualifying characteristics. HCFA has estimated that there may be as

many as 50,000 such HIV-infected individuals covered by Medicaid.

18As of June 1, 1997, 44 percent of participants in HIV Insight—IMS America’s longitudinal database of

more than 7,500 individuals with HIV/AIDS—were receiving triple combination therapy.

19These estimates are conservative. The researchers’ percentages are for all HIV-infected individuals,

both those with AIDS and those whose disease has not yet progressed to AIDS, some of whom may not

be seeking treatment because they are unaware of their infection. However, under current treatment

guidelines, all AIDS patients are considered candidates for the combination therapy.

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Increases in ADAP

Participation Also Likely as

a Result of Those Seeking

Combination Therapy

It is difficult to estimate the number of individuals who will ultimately

seek ADAP coverage for combination drug therapy. However, recent

experiences show a steadily increasing demand for ADAP services.

Unlike estimates of the number of people seeking coverage through

Medicaid, estimates of the number of individuals who qualify for

combination therapy under the ADAPs cannot be made. This is because, in

addition to AIDS patients, ADAPs’ clients include people who are HIV positive

but do not yet have AIDS. It is this latter group for whom limitations on data

make it impossible to estimate the total candidate population for the

therapy. In addition, states have varying financial and medical standards

individuals must meet to qualify for ADAP services, so this subset of

candidate patients cannot be computed. Furthermore, because these

individuals finance their care through multiple funding sources, some

individuals only qualify for ADAP benefits for part of the year.

The only information that is available for predicting the likely future

demand for ADAP coverage is the recent experience of the ADAP programs.

Since 1992, the number of people seeking funding for AIDS therapies

through ADAPs has increased rapidly. In calendar year 1996, ADAPs served a

total of about 80,000 clients nationwide, compared with about 50,000 in

1994. Comparing states’ ADAP caseloads for July 1996 and July 1997—the

most recent data available—shows that per-month client use of ADAPs

increased 39 percent overall, from about 31,000 to more than 43,000. A

survey by the National Alliance of State and Territorial AIDS Directors

shows the number of patients served by ADAPs increasing at a rate of 1,000

per month.20 Per-month expenditures increased 78 percent overall, from

nearly $15 million to more than $27 million. (For a state-by-state profile of

ADAPs, see app. IV.)

HHS has reported that as early as mid-1996 some ADAPs had 80 percent or

more of their clients receiving combination drug therapy.21 The ADAP

Working Group has made projections for expected ADAP enrollment and

drug utilization through the year 2000.22 It projects that the rate of ADAP

clients receiving combination drug therapy over the next 2 years will be

20National Alliance of State and Territorial AIDS Directors and AIDS Treatment Data Network,

National ADAP Monitoring Project: Interim Technical Report, prepared for the Henry J. Kaiser Family

Foundation (Washington, D.C.: Mar. 1998).

21HHS, Office of the Deputy Secretary, Access to HIV-Related Drug Therapies (Washington, D.C.:

June 1997).

22The ADAP Working Group is a consortium of AIDS activist organizations, pharmaceutical companies,

and other organizations.

Page 12 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

90 percent. The higher proportion of ADAP clients receiving combination

therapy, compared with expected rates for Medicaid patients, likely

reflects the somewhat different patient population who may seek coverage

by the ADAP precisely because they have been prescribed high-cost drug

treatment.

Increase in ADAP

Participation Has

Prompted States to Seek

Measures to Stretch

Strained ADAP Resources

ADAPs have implemented a number of measures in an effort to stretch their

limited resources. These measures include cross-checking program

enrollment with Medicaid, discount drug pricing, and emergency measures

such as establishing waiting lists.23 Yet even with these cost containment

efforts, the National Alliance of State and Territorial AIDS Directors found

that more than one-fifth of the programs expect budget shortfalls for

1998.24

ADAPs Check Client Eligibility

for Medicaid

To ensure that program dollars are spent wisely, a number of ADAPs have

taken steps to help identify the most appropriate source of assistance for

clients and individuals seeking prescription drug benefits. Many

individuals seeking ADAP coverage may not be aware that they are eligible

for assistance through other sources, such as Medicaid. Additionally, some

may be eligible for prescription drug benefits under more than one

program.

In our contacts with officials from the 10 largest ADAPs25—which

collectively account for about 70 percent of total federal ADAP funding—we

found that most cross-check Medicaid eligibility and verification files at

initial enrollment and on an ongoing basis, although the frequency with

which they updated Medicaid eligibility status varied significantly. For

example, New York updates the information weekly, while others do so

monthly or less often. Most of these ADAPs are linked to the Medicaid files

via computer for both initial screening and cross-checks. States also use

other means to verify eligibility. For example, Virginia requires all ADAP

clients to apply to Medicaid within 90 days of enrollment. In Puerto Rico,

in lieu of computer linkages to Medicaid, case managers work with clients

to check for Medicaid or ADAP coverage. (See table 3.)

23HRSA officials told us that states may also take other, less direct measures, that can reduce the need

for ADAP services, such as limiting the caps that insurers can place on prescription drug benefits or

extending health care coverage to the working poor.

24National ADAP Monitoring Project: Interim Technical Report (Mar. 1998).

25Size was based on the proportion of federal funding, using the CARE Act title II base funds and ADAP

supplemental funding. These programs also serve the most clients, based on recent reports.

Page 13 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Table 3: Procedures Used by 10

Largest ADAPs to Check Client

Eligibility for Medicaid

State Procedure(s) for determining Medicaid eligibility

New York Checks applicants initially for Medicaid eligibility and does a

weekly computerized check against Medicaid rolls.

California Gives applicants provisional coverage while Medicaid application

is pending; does monthly cross-checks with Medicaid status.

Florida Initially checks Medicaid eligibility; pharmacies also check before

dispensing drugs. Periodically cross-matches ADAP and Medicaid

files.

Texas Uses a computer link to check Medicaid status of applicants;

20-25% of ADAP clients are on Medicaid. ADAP covers drugs

beyond the state Medicaid limit of three prescriptions per month.

New Jersey Does an initial check of Medicaid eligibility and a monthly check

against Medicaid file.

Puerto Rico Checks applicants for eligibility for Medicaid and local government

health insurance programs; reevaluates eligibility periodically but

does no computerized checks.

Georgia Requires applicants to apply for Medicaid and gives them

provisional coverage while Medicaid application is pending. They

are accepted into ADAP only if rejected for Medicaid. Does no

computerized checks against Medicaid database.

Illinois Checks applicants against Medicaid database and checks again

each time applicant fills a prescription.

Virginia Requires applicants to apply for Medicaid and show proof of

application within 90 days, cross-checks them against Medicaid

database, and reassesses eligibility annually.

Pennsylvania Does an initial check of Medicaid eligibility, a periodic

reassessment of eligibility, and has a direct computer link to

cross-check against applicant Medicaid enrollment.

Note: State ADAPs are listed in decreasing order of size.

A recent study of all ADAPs similarly found that 39 states require their ADAPs

to cross-check client eligibility for Medicaid, mostly through direct access

to Medicaid data or through screening by case managers.26 The study

points out that 19 of the 23 states with limited Medicaid coverage have

restricted ADAP access.27 This suggests that the expansiveness of a state’s

Medicaid program may directly affect the demand for ADAP services. For

example, the Medicaid programs in Mississippi, Oklahoma, and Texas are

among 11 state programs that have placed limits on the number of

prescriptions available each month; at the same time, the ADAPs in these

26See National ADAP Monitoring Project: Interim Technical Report.

27The study defines “limited” Medicaid programs by one or more of the following: (1) no medically

needy eligibility category, (2) low spend-down income eligibility threshold (less than 50 percent of the

federal poverty level, and (3) monthly prescription limits with no exceptions for chronic illnesses (for

example, HIV/AIDS).

Page 14 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

states have not been able to meet the demand and have had to develop

waiting lists. Figure 1 shows the restrictiveness of the Medicaid and ADAP

programs in the various states.

Page 15 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Figure 1: Restrictiveness of Medicaid and ADAP Coverage in States

Source: National Alliance of State and Territorial AIDS Directors and the AIDS Treatment Data

Network, March 1998.

Page 16 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Discount Pricing Reduces

ADAP Expenditures

Most ADAPs have reduced their expenditures on HIV and AIDS drugs through

several discount pricing methods. For example, under the Veterans’ Health

Care Act of 1992 (which enacted section 340B of the Public Health Service

Act), ADAPs—as well as state Medicaid programs—can obtain drugs at a

minimum 15.1-percent discount below the average manufacturer price.

ADAPs that cannot obtain up-front drug discounts may negotiate voluntary

manufacturer rebates of certain drugs. Some ADAPs seek discounts from

retail pharmacies, receive third-party partial insurance reimbursements

(when available), collect copayments for drugs from clients, or obtain

reimbursement coverage from Medicaid if a client becomes eligible for

that program.

However, not all ADAPs have obtained the lowest prices available in

purchasing drugs. According to a recent HHS Inspector General’s report,

only 19 of the 53 ADAPs participated in the 340B drug pricing program in

fiscal year 1996.28 Many of the nonparticipating programs cited the list of

administrative burdens as a disincentive. However, a recent HHS policy

change will allow ADAPs to participate more readily in this program by the

use of a rebate mechanism. For the sample of nonparticipating ADAPs that

it examined, the Inspector General estimated that they could have

purchased an additional 8 percent of drug therapies if they had

participated in the 340B program.

Emergency Measures Taken by

Some ADAPs

Regardless of these efforts, with the increase in the number of people

seeking assistance, many states have found it difficult to adequately fund

their ADAPs. Some states have cut costs by restricting patient access to

ADAPs and implementing other emergency measures.

According to a study published by the National Alliance of State and

Territorial AIDS Directors, in fiscal year 1997, 22 states implemented

emergency measures to contain costs.29 These problems have occurred

most frequently near the end of the time period for which the title II

funding grant is provided. Twelve states moved funds from other CARE Act

budget categories, such as home health care, and other sources; 10 states

capped program enrollment; and 9 states restricted access to protease

inhibitors. Thirteen states noted that they would likely exhaust their funds

before more funding would be made available. Nine states reported that

28HHS, Office of Inspector General, Audit of State AIDS Drug Assistance Programs’ Use of Drug Price

Discounts, No. A-01-97-01501 (Washington, D.C.: Jan. 1998).

29See National ADAP Monitoring Project: Interim Technical Report.

Page 17 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

they maintained waiting lists for ADAP enrollment, while seven states

maintained waiting lists for current clients to obtain protease inhibitors.30

As of July 1998, 19 ADAPs had some type of restrictions on their services.

As shown in table 4, these limitations included capping enrollment and

expenditures and maintaining waiting lists.

Table 4: Summary of Program

Limitations Reported by Grantees for

ADAP Services, July 1998 Type of program

limitation

Number of

ADAPs reporting

limitation Grantees reporting limitation

All ADAP services

Capped enrollment

11

Alabama, Alaska, Florida, Georgia,

Idaho, Indiana, Montana, Nevada, North

Carolina, Oklahoma, and South Dakota

Waiting list

9

Florida, Georgia, Idaho, Indiana,

Montana, Nevada, North Carolina,

Oklahoma, and South Carolina

Capped expenditures

5

Illinois, Missouri, Oklahoma, South

Dakota, and Wyoming

Protease inhibitors

Capped enrollment

7

Idaho, Kentucky, Maine, Mississippi,

Missouri, Nevada, and Oklahoma

Waiting list

6

Arkansas, Idaho, Maine, Mississippi,

Nevada, and South Carolina

Other limits

3

Arkansas and South Dakota (not

dispensing protease inhibitors) and

Mississippi (medical criteria vary by

medication)

Source: HHS.

Impact of New

Therapies on Public

Programs Is Difficult

to Assess, but Effects

on Programs Would

Likely Vary

As discussed, it is not possible to accurately project the number of

patients who will be on combination drug therapy in the future. It is

therefore difficult to assess the likely impact of the new therapies on

public programs. Many factors—such as the long-term effectiveness of

current therapies, evolving standards of care, and new research

developments—influence future demand and cost. Regardless of the

overall effect of the new therapies on public programs, the impacts are

30ADAP programs in 22 states have transferred funds from other health programs, capped program

enrollment, or capped or restricted access to protease inhibitors: Alabama, District of Columbia,

Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Maine, Mississippi, Missouri, Montana,

Nebraska, Nevada, New Mexico, North Carolina, Oklahoma, South Carolina, South Dakota, West

Virginia, and Wyoming.

Page 18 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

likely to be different for the Medicaid program and for health care funded

through the CARE Act.

Long-Term Impact of Drug

Therapies Would Influence

Demand and Associated

Costs

Rapid advances in HIV and AIDS treatment have occurred in the last 2 years.

Researchers are identifying optimal standards of care, which are now a

part of federal treatment guidelines. Such information—as well as ongoing

research and discoveries—will likely influence the demand for these new

drugs and therapies and their effect on public programs.

The long-term effectiveness of protease inhibitors and combination drug

therapies is largely unknown. Patient outcomes will likely influence the

number of individuals who seek combination therapy in the future. For

example, patients responding well to drug therapy may be removed from

the therapy after a few years to determine whether the virus has been

eliminated. Patients whose conditions cannot be stabilized may also be

removed from the therapy or they may continue to receive therapy

because they still benefit from the drugs. Other patients may over time

develop a resistance to drugs that initially succeeded in stabilizing or

reducing their viral load. Some patients may not be able to tolerate the

drugs because of side effects and would thus be removed from the therapy

after a brief period.

Standards of care will also likely influence the demand for combination

drug therapy treatment and the associated costs. Just as the recently

released NIH standards of clinical care for HIV and AIDS have greatly

expanded the candidate population who qualify for treatment, changes in

these standards could alter the number of individuals seeking the therapy.

Other new drugs and therapies would also likely have an effect on demand

and cost. The National Institute of Allergy and Infectious Diseases is

currently supporting research on the development of HIV vaccines, and a

number of new drugs for HIV infection and AIDS-associated opportunistic

infections are either being developed or tested. At the same time,

investigations into exactly how HIV damages the immune system is

suggesting new and more effective methods of treatment.

Researchers do not yet know how many years people with HIV or AIDS

might maintain a combination therapy regimen or how long their lives

might be extended. If the new drugs and therapies slow or halt HIV’s

progression to AIDS, other costs associated with the care of people with

Page 19 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

AIDS—such as hospitalizations, support services, and long-term care—may

be effectively delayed.

Some evidence already suggests that the new combination therapies have

noticeably lowered the current utilization of inpatient hospital services.

For example, at the 4th Conference on Retroviruses and Opportunistic

Infections held in January 1997, state and hospital officials demonstrated

reduced hospitalization rates, suggesting new HIV and AIDS drugs as a

possible cause.31 A recent study by VA attributes a 37-percent decrease in

the number of hospitalizations and a 41-percent decrease in the number of

hospital days at 173 VA medical centers to the combination therapies. This

study cites an $18 million net cost savings in 1997 in contrast with 1996.32

Public health officials in New York City also announced a 50-percent drop

in AIDS deaths from the last quarter of 1995 to the same quarter in 1996,

citing as a partial reason the new HIV and AIDS drugs. Researchers at Johns

Hopkins University pointed out that if a person with AIDS avoided a single

hospitalization—which averages $7,000 per stay—in 1 year, the costs

associated with combination drug therapy for the same individual could be

completely offset. However, if the drugs extended the life of a person with

HIV or AIDS, it is possible that at some point the cost of the drugs would

exceed the amount that would have been spent on hospitalizations and

other treatments. Finally, hospitalization costs might simply be delayed.

Another analysis by the Johns Hopkins University AIDS researchers sought

to examine the cost-effectiveness of combination therapy.33 The model

used in this study projected an incremental cost-effectiveness for triple

therapy of $10,000 to $18,000 per life-year gained. They compared the cost

per life-year saved of triple-drug therapy with the cost per life-year saved

for accepted treatments for other medical conditions and found that it is

within the range of other treatments for other diseases and conditions.

(See table 5.)

31Ramon Torres, Medical Director of the AIDS Center at St. Vincent’s Hospital and Medical Center in

New York, showed that the new HIV and AIDS drugs have significantly reduced hospitalizations, many

of which were for patients who were more likely to receive assistance from Medicaid and the ADAPs

than from private insurance companies.

32R.D. Moore, The Hopkins HIV Report (Baltimore, Md.: Johns Hopkins AIDS Services, Sept. 1998).

33R.D. Moore and J.G. Bartlett, “Combination Antiretroviral Therapy in HIV Infection: An Economic

Perspective,” PharmacoEconomics, Vol. 2, No. 10 (1996), pp. 109-13.

Page 20 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

Table 5: Cost per Life-Year Saved of

Protease Inhibitor Regimens

Compared With Other Selected

Medical Treatments

Medical treatment Cost per life-year saved

Triple-drug therapy for HIV $10,000-$18,000

Enalapril for congestive heart failure 9,700

Lovastatin to prevent coronary disease 21,000

Renal hemodialysis 50,000

Warfarin for nonvascular atrial fibrillation, patients aged 75

years or older 110,000

Coronary bypass surgery, 50-year-old men with

triple-vessel disease 113,000

Source: Moore and Bartlett, PharmacoEconomics, p. 111.

Different Impacts of Drug

Therapies Anticipated for

Medicaid and ADAPs

Although drug treatment costs per person would essentially be the same

for individuals receiving assistance from Medicaid and from ADAPs, the

effect on these two programs would likely be different. For Medicaid,

reductions in hospitalizations could, in the short-term, offset the costs

associated with HIV and AIDS combination drug therapy. However, in the

longer term, program costs may not be offset if hospitalizations are merely

delayed.

For ADAPs, increases in the number of people who seek assistance for

combination drug therapies would not be offset by fewer hospitalizations,

because ADAPs only cover the cost of prescription drugs, not

hospitalizations. However, delaying the onset of AIDS, its symptoms, and

associated diseases and conditions could, in the short term, reduce the

need for other services funded under the CARE Act. For example, under

title I, the CARE Act provides 49 metropolitan areas disproportionately

affected by the AIDS epidemic with funding for mental health treatment,

case management, support services, and substance abuse programs for HIV

and AIDS patients. Arguably, if the new HIV and AIDS drugs successfully

delayed the onset of AIDS, the demand for a number of these services might

be postponed, at least for the period of time the drugs are effective. On the

other hand, the success of drug therapies might increase the amount of

time that clients are enrolled and the use of related support and diagnostic

services. Moreover, it is not clear that clients served under other titles of

the CARE Act are the same as those served under ADAP.

In light of NIH’s recently published standards of care, people with HIV who

are asymptomatic may seek combination therapies in greater numbers.

The development of new drugs and therapies, such as quadruple therapy,

Page 21 GAO/HEHS-99-2 HIV/AIDS Drugs
B-276444 

would likely add to the prescription drug demand. Although insurance

coverage for the estimated 410,000 to 660,000 individuals who are HIV

positive but have not developed AIDS is unknown, ADAPs are the most likely

to see increases in the number of individuals who are uninsured or

underinsured and seeking funding for combination drug therapy in 1998.

HHS officials anticipate that welfare reform efforts will likely cause ADAP

enrollment to increase. As individuals transition from Medicaid and obtain

employment, they will more likely become qualified for ADAP benefits. And

if treatment fails, individuals will still need care provided through other

services funded through CARE Act programs.

Agency Comments We obtained comments on a draft of this report from HHS and from two

expert reviewers. HHS and the expert reviewers made technical comments,

which we incorporated where appropriate. In particular, HHS was

concerned that we had not accounted for the different characteristics and

service needs of clients served by the ADAPs and other programs funded by

the CARE Act. We added information to the report to take these

complexities into account. In addition, HHS provided projections of the

number of people with AIDS covered by Medicaid in 1998 that HCFA

actuaries believed were more precise than those in our draft. We modified

our report to reflect the HCFA estimate.

We will make copies of this report available to interested parties upon

request.

Please call me at (202) 512-7119 or Marcia Crosse, Assistant Director, at

(202) 512-3407 if you have any questions about this report. Other

contributors to this report include Lawrence S. Solomon, Project Manager;

Nila Garces-Osorio, Social Science Analyst; and Karen Sloan,

Communications Analyst.

Marsha Lillie-Blanton

Associate Director, Health Services Quality

 and Public Health Issues

Page 22 GAO/HEHS-99-2 HIV/AIDS Drugs
Page 23 GAO/HEHS-99-2 HIV/AIDS Drugs
Contents

Letter 1

Appendix I 

Financial Criteria for

Medicaid and ADAP

Eligibility

26

Appendix II 

State ADAP Funding

31

Appendix III 

EMA Contributions to

ADAPs

33

Appendix IV 

State-by-State Profile

of ADAPs

34

Tables Table 1: Recent Federal and State Spending Estimates for All

HIV- and AIDS-Related Drugs Through Medicaid and ADAPs

8

Table 2: CARE Act Federal Funding Levels, by Title 9

Table 3: Procedures Used by 10 Largest ADAPs to Check Client

Eligibility for Medicaid

14

Table 4: Summary of Program Limitations Reported by Grantees

for ADAP Services, July 1998

18

Table 5: Cost per Life-Year Saved of Protease Inhibitor Regimens

Compared With Other Selected Medical Treatments

21

Table I.1: Medicaid and State ADAP Financial-Based Criteria for

Program Eligibility

27

Table II.1: State Funding Contributions for ADAP and Percentage

Change, Fiscal Years 1995, 1996, and 1997

31

Table III.1: Title I EMA Contributions to ADAPs and Percentage

Change, Fiscal Years 1995, 1996, and 1997

33

Table IV.1: Number of Clients Served by ADAPs and ADAP

Expenditures, July 1996, January 1997, and July 1997

34

Page 24 GAO/HEHS-99-2 HIV/AIDS Drugs
Contents

Figure Figure 1: Restrictiveness of Medicaid and ADAP Coverage in

States

16

Abbreviations

ADAP AIDS Drug Assistance Program

AFDC Aid to Families With Dependent Children

AIDS acquired immunodeficiency syndrome

CARE Comprehensive AIDS Resources Emergency

CDC Centers for Disease Control and Prevention

DOD Department of Defense

EMA eligible metropolitan area

FDA Food and Drug Administration

FPL federal poverty level

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HMO health maintenance organization

HRSA Health Resources and Services Administration

HUD Department of Housing and Urban Development

NIH National Institutes of Health

SSI Supplemental Security Income

VA Department of Veterans Affairs

Page 25 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix I 

Financial Criteria for Medicaid and ADAP

Eligibility

Within broad federal guidelines, states have flexibility in developing their

Medicaid programs, including requirements for eligibility and prescription

drug benefits. Medicaid covers all prescribed HIV and AIDS drugs approved

by the Food and Drug Administration (FDA) consistent with the

requirements of 1927(d) of the Social Security Act. The Health Care

Financing Administration (HCFA) surveyed state Medicaid programs and

found that all states were covering protease inhibitors, as required.

Because of prescription limits, however, combination therapy, with its

dependence on multiple drugs, can rapidly exceed these limits (for

example, 11 states limit the number of allowable drugs to as few as three

per month).34 Thirty-one programs require nominal copayments for the

drugs.

Generally, state AIDS Drug Assistance Programs (ADAP) cover many

FDA-approved HIV and AIDS drugs, but not all drugs are covered by each

program. To assess financial eligibility for ADAP enrollment, most states

use federal poverty guidelines; income limits are often expressed as a

percentage of the federal poverty level (FPL). The financial requirements

range from 100 percent of FPL in one state to 558 percent of FPL in another

state. Some states list the requirement in terms of absolute income levels:

for example, as long as liquid assets total less than $25,000, New York

requires a household of one to earn no more than $44,000; a household of

two, less than $59,200; and three or more, less than $74,400. Other states

also use specific income levels unrelated to the federal poverty guidelines.

Some programs consider out-of-pocket medical expenses when

determining income. Ten of the programs restrict financial assets. (See

table I.1.)

States have both financial and medical requirements for ADAP enrollment.

For example, a person must have an income or assets below a certain

dollar amount or demonstrate financial hardship. At a minimum, a person

must be diagnosed as having HIV infection. Almost half of the states have

only these basic requirements. Other states also require that a client have

CD4 counts less than a certain level (CD4 is a measure of the immune

system level). For example, six states require a CD4 level of less than 500.

Twelve states require a doctor’s prescription for the HIV and AIDS drugs.

Some states also test the HIV viral load in order to determine medical

eligibility.35

34Arkansas, California, Florida, Georgia, Mississippi, Nevada, North Carolina, Oklahoma, South

Carolina, Texas, and Wyoming all impose limits on the number of prescriptions. However, some states

allow exceptions for chronic illnesses.

35Tests of the viral load assess the level of HIV RNA, a genetic material, in the blood.

Page 26 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix I 

Financial Criteria for Medicaid and ADAP

Eligibility

Table I.1: Medicaid and State ADAP Financial-Based Criteria for Program Eligibility

State

Medicaid criteria as of 1997:a,b

applicant qualified for AFDC as

of July 1996 or SSI, or had

income . . . ADAP criteria

Alabama at or below 133% of FPL for

pregnant women and infants

Income at or below 250% of FPL; no third-party insurance that pays for more

than 50% of the cost of covered medications

Alaska at or below 133% of FPL for

pregnant women and infants

Income at or below 300% of federal poverty guidelines for Alaska

Arizona at or below 140% of FPL for

pregnant women and infants

Income at or below 200% of FPL

Arkansas at or below 133%-200% of FPL for

pregnant women and infantsc

Income at or below 100% of FPL less medical expenses; usually covers any

uninsured person until insurance begins

California at or below 200% of FPL for

pregnant women and infants

Income at or below 400% of FPL; if income is above limit, sliding-scale

copayment is based on annual state income tax liability and family size, up to

annual earnings of $50,000; applicant’s health insurance does not provide

drugs as a benefit, or the copayment plan is causing financial hardship, or

applicant is not enrolled in a health maintenance organization (HMO), health

insurance program, or public program

Colorado at or below 133% of FPL for

pregnant women and infants

Income at or below 185% of FPL

Connecticut at or below 185% of FPL for

pregnant women and infantsd

Income at or below 300% of FPL; no asset limitations

Delaware at or below 185% of FPL for

pregnant women and infants

Income at or below 230% of FPL, no copayment; sliding-scale copayments

for cost of service, and total allowable annual charges cannot exceed either

7% or 10% of gross income, depending on the copayment

District of Columbia at or below 185% of FPL for

pregnant women and infants

Income at or below 300% of FPL

Florida at or below 185% of FPL for

pregnant women and infants

Income at or below 200% of FPL; enrollees with incomes 100%-200% of FPL

are assessed for sliding-scale copayments

Georgia at or below 185% of FPL for

pregnant women and infants

Income at or below 125% of FPL

Hawaii at or below 300% of FPL for

pregnant women and infantsd,e

Income at or below 400% of FPL set for Hawaii; assets less than $10,000,

excluding home and car

Idaho at or below 133% of FPL for

pregnant women and infants

Income at or below 400% of FPL

Illinois at or below 133% of FPL for

pregnant women and infantsd

Income at or below 200% of FPL; insurance provides less than 80% of cost of

prescription medication

Indiana at or below 150% of FPL for

pregnant women and infantsd

Indiana residency requirement and income at or below 300% of FPL

Iowa at or below 185% of FPL for

pregnant women and infants

Income at or below 200% of FPL

Kansas at or below 150% of FPL for

pregnant women and infants

Income at or below 300% of FPL; will assist with spend-down

(continued)

Page 27 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix I 

Financial Criteria for Medicaid and ADAP

Eligibility

State

Medicaid criteria as of 1997:a,b

applicant qualified for AFDC as

of July 1996 or SSI, or had

income . . . ADAP criteria

Kentucky at or below 185% of FPL for

pregnant women and infants

Income at or below 300% of FPL, adjusted for family size; cash assets less

than $10,000; access to protease inhibitors requires income at or below

200% of FPL, adjusted for family size

Louisiana at or below 133% of FPL for

pregnant women and infants

Income at or below 200% of FPL; assets less than $4,000, excluding home

and car; not qualified for Medicaid or private insurance

Maine at or below 185% of FPL for

pregnant women and infants

Income at or below 200% of FPL

Maryland at or below 185% of FPL for

pregnant women and infantse

Income equal to or less than $29,400, adjusted for household size;

sliding-scale copayments for incomes over $26,000

Massachusetts at or below 185% of FPL for

pregnant women and infants

Income at or below $27,000; limit raised by $2,200 for each dependent

Michigan at or below 185% of FPL for

pregnant women and infants

Income at or below 362% of FPL; must have applied for Medicaid within the

past 60 days and have pending or denial status; not eligible for VA benefits

Minnesota at or below 275% of FPL for

pregnant women and infantsd,e

Income at or below 300% of FPL; liquid assets less than $25,000, excluding

home and car; uninsured or responsible for 20% or more of prescription cost

or $15 or more per prescription; cannot be in state Medical Assistance or

General Assistance Medical Care programs

Mississippi at or below 185% of FPL for

pregnant women and infants

Household income below 200% of FPL

Missouri at or below 185% of FPL for

pregnant women and infantsd

Income at or below 185% of FPL

Montana at or below 133% of FPL for

pregnant women and infants

Applicant must provide evidence that the cost of the covered medications

will create a severe household financial burden

Nebraska at or below 150% of FPL for

pregnant women and infants

Income at or below 200% of FPL

Nevada at or below 133% of FPL for

pregnant women and infants

Income at or below 200% of FPL; less than $4,000 in assets, excluding home

and car

New Hampshire at or below 185% of FPL for

pregnant women and infantsd

Income at or below 300% of FPL (income limit may be adjusted on basis of

medical expenses incurred)

New Jersey at or below 185% of FPL for

pregnant women and infants

Income equal to or less than $30,000 for one person; limit increased by

$10,000 for each member of household, up to $70,000 per year

New Mexico at or below 185% of FPL for

pregnant women and infants

Income at or below 300% of FPL, adjusted for family size; liquid assets of

less than $10,000

New York at or below 185% of FPL for

pregnant women and infants

Income at or below $44,000 for a household of one, less than $59,200 for

two, less than $74,400 for three or more; liquid assets less than $25,000

North Carolina at or below 185% of FPL for

pregnant women and infants

Income at or below 125% of FPL

North Dakota at or below 133% of FPL for

pregnant women and infantsd

Income at or below 150% of FPL; sliding-scale coverage above 150% of FPL

Ohio at or below 133% of FPL for

pregnant women and infantsd

Income at or below 281% of FPL, currently less than $1,410 per month after

taxes (additional allowance for dependents)

Oklahoma at or below 150% of FPL for

pregnant women and infantsd

Income at or below 150% of FPL (out-of-pocket drug costs can spend-down)

(continued)

Page 28 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix I 

Financial Criteria for Medicaid and ADAP

Eligibility

State

Medicaid criteria as of 1997:a,b

applicant qualified for AFDC as

of July 1996 or SSI, or had

income . . . ADAP criteria

Oregon at or below 133% of FPL for

pregnant women and infants

Income at or below 250% of FPL

Pennsylvania at or below 185% of FPL for

pregnant women and infants

Gross income less than $30,000, with an allowance of $2,480 for each

additional family member

Puerto Rico Not available Certified medically indigent by Medicaid or limited or no coverage by a drug

prescription plan, as documented by the state, health insurance plan,

consortia, or community-based organization; guidelines for income start at

between $400 and $800 per month for one person

Rhode Island at or below 250% of FPL for

pregnant women and infantse

Income at or below 400% of FPL

South Carolina at or below 185% of FPL for

pregnant women and infants

Income at or below 300% of FPL for free medications; a sliding fee scale

determines applicant’s payment above this threshold

South Dakota at or below 133% of FPL for

pregnant women and infants

Income at or below 300% of FPL

Tennessee at or below 400% of FPL for

pregnant women and infantse

Income at or below 300% of FPL; liquid asset limit of $8,000

Texas at or below 185% of FPL for

pregnant women and infants

Income at or below 200% of FPL (if married, spouse’s income is counted);

not eligible for Medicaid or used up the month’s Medicaid pharmacy benefit;

copayment of $5 per prescription may be required for clients not eligible for

Medicaid; income guidelines for households of 1 person, less than $15,480,

2 people, less than $20,720, 3 people, less than $25,960, 4 people, less than

$31,200, 5 people, less than $36,440

Utah at or below 133% of FPL for

pregnant women and infants

Full coverage at or below 100% of FPL; sliding scale and copayment for

incomes over 100% of FPL

Vermont at or below 200%-225% of FPL for

pregnant women and infantsf

Income at or below 200% of FPL; sliding scale and copayments for incomes

over 200% of FPL

Virginia at or below 133% of FPL for

pregnant women and infantsd

Income at or below 200% of FPL (residents of northern Virginia may have

incomes up to $17,428)

Washington at or below 185%-200% of FPL for

pregnant women and infantsf

Income at or below 370% of FPL; assets less than $10,000, excluding home

and car

West Virginia at or below 150% of FPL for

pregnant women and infants

Income at or below 300% of FPL

Wisconsin at or below 185% of FPL for

pregnant women and infants

Income at or below 200% of FPL; must have applied for coverage under, and

have been denied eligibility for, medical assistance within 12 months of

application

Wyoming at or below 133% of FPL for

pregnant women and infants

Income at or below 300% of FPL

(Table notes on next page)

Page 29 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix I 

Financial Criteria for Medicaid and ADAP

Eligibility

aStates are required to provide Medicaid coverage to children aged 6 and older born after

September 30, 1983, living in families with incomes below 100 percent of the federal poverty

level. Since 1989, states have been required to cover all pregnant women as well as children

below age 6 living in families with incomes at or below 133 percent of the federal poverty level.

bWelfare reform generally severed the link between cash assistance programs and Medicaid

eligibility. Under the Temporary Assistance for Needy Families block grant, the open-ended

entitlement to cash assistance for eligible families was eliminated. To ensure continued Medicaid

coverage for low-income families, the law generally set Medicaid eligibility standards at AFDC

levels in effect on July 16, 1996.

cIn Arkansas, pregnant women are covered at 133 percent of FPL and infants are covered up to

200 percent of FPL.

dEleven states elected to retain the more restrictive Medicaid eligibility criteria that were in place

for blind, disabled, and elderly beneficiaries before SSI was established in 1972. These states

may use more restrictive definitions of disability or more restrictive financial eligibility criteria than

SSI.

eHawaii, Maryland, Minnesota, Rhode Island, and Tennessee operate programs under Section

1115 waivers. Some populations receive fully subsidized Medicaid services. Other populations

are required to pay a portion of the premium and may have a different benefit package.

f

In Vermont, pregnant women are covered at 200 percent of FPL and infants are covered up to

225 percent of FPL. In Washington, the income eligibility criterion for pregnant women is

185 percent of FPL; the income eligibility criterion for infants is 200 percent of FPL.

Sources: National Governors’ Association, Medicaid Eligibility of Pregnant Women, Infants, and

Children, Effective October 1997 (Washington, D.C.: Oct. 1997); National Alliance of State and

Territorial AIDS Directors and AIDS Treatment Data Network, National ADAP Monitoring Project:

Interim Technical Report (Washington, D.C.: Mar. 1998) and State AIDS Drug Assistance

Programs: A National Status Report on Access (Washington, D.C.: July 1997).

Page 30 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix II 

State ADAP Funding

In fiscal year 1997, a total of 34 states (plus the District of Columbia and

Puerto Rico) provided funds to their ADAPs in addition to the funds

provided by the federal government. The state contributions have

increased from a total of $28.7 million in 1995 to $98.1 million in 1997 (see

table II.1).

Table II.1: State Funding Contributions for ADAP and Percentage Change, Fiscal Years 1995, 1996, and 1997

State funding amounts State % of total funding

State FY 1995 FY 1996 FY 1997

Percentage

change,

1995-97 FY 1995 FY 1996 FY 1997

Percentage

change,

1995-97

Alabama a $150,000 $150,604 b a 6% 5% b

Alaska c 0 0 b c 0 0 b

Arizona 0 0 600,000 b 0 0 18 b

Arkansas 9,657 0 0 (–100) 2 0 0 (–100)

California 9,100,000 15,600,000 40,200,000 342 52 41 51 (–4)

Colorado 150,000 301,000 301,000 101 27 24 11 (–59)

Connecticut 592,000 592,000 592,000 0 43 24 14 (–67)

Delaware 0 35,000 0 0 0 8 0 0

District of Columbia 0 147,000 800,000 b 0 6 15 b

Florida 42,000 0 1,500,000 3,471 1 0 5 400

Georgia 324,000 324,450 324,450 0 19 7 4 (–79)

Hawaii 265,000 300,000 291,000 10 66 42 26 (–61)

Idaho 0 0 0 0 0 0 0 0

Illinois 2,197,493 5,200,000 8,325,000 279 63 58 58 (–10)

Indiana 0 75,000 442,000 b 0 5 17 b

Iowa 0 0 0 0 0 0 0 0

Kansas 0 0 0 0 0 0 0 0

Kentucky 99,970 110,000 127,944 28 23 13 11 (–52)

Louisianad 0 0 0 0 0 0 0 0

Maine 60,040 60,040 60,000 0 67 25 15 (–78)

Maryland 85,688 1,100,000 600,000 600 11 24 10 (–9)

Massachusetts 1,290,000 1,100,000 6,800,000 427 71 34 60 (–15)

Michigan 0 0 0 0 0 0 0 0

Minnesota 0 150,000 150,000 b 0 26 15 b

Mississippi 0 0 0 0 0 0 0 0

Missouri 0 600,000 600,000 b 0 37 11 b

Montana a 95,000 0 b a 42 0 b

Nebraska 0 0 0 0 0 0 0 0

Nevada 0 0 1,300,000 b 0 0 46 b

(continued)

Page 31 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix II 

State ADAP Funding

State funding amounts State % of total funding

State FY 1995 FY 1996 FY 1997

Percentage

change,

1995-97 FY 1995 FY 1996 FY 1997

Percentage

change,

1995-97

New Hampshire 100,000 73,833 0 (–100) 48 17 0 (–100)

New Jersey 0 875,000 700,000 b 0 9 4 b

New Mexico 650,000 740,000 740,000 14 100 64 38 (–62)

New York 495,120 8,400,000 9,900,000 1,900 2 15 14 600

North Carolina 450,000 750,000 750,000 67 100 35 20 (–80)

North Dakota 0 0 0 0 0 0 0 0

Ohio 200,500 200,000 3,124,500 1,458 19 10 48 153

Oklahoma 206,000 206,000 431,000 109 37 20 21 (–43)

Oregon 0 0 0 0 0 0 0 0

Pennsylvania 4,703,000 5,200,000 6,659,347 42 100 76 56 (–44)

Puerto Rico 3,406,651 3,406,651 4,168,036 22 49 42 32 (–35)

Rhode Island 0 0 0 0 0 0 0 0

South Carolina 50,000 350,000 500,000 900 11 21 14 27

South Dakota 0 0 0 0 0 0 0 0

Tennessee 0 0 610,050 b 0 0 25 b

Texas 2,708,838 2,697,376 2,697,736 0 65 32 14 (–80)

Utah 114,000 114,800 114,800 0 54 17 15 (–72)

Vermont a 0 150,000 b a 0 38 b

Virginia 786,800 687,200 687,200 (–13) 56 18 11 (–80)

Washington 240,000 417,500 3,263,000 1,260 50 26 53 6

West Virginia 0 25,000 74,833 b 0 11 9 b

Wisconsin 393,700 295,800 373,500 (–5) 93 35 25 (–73)

Wyoming 0 0 0 0 0 0 0 0

Total $28,720,457 $50,378,650 $98,108,000 242 31 24 25 (–19)

aNot available.

bPercentage change cannot be calculated.

cState had no ADAP that year.

dLouisiana does not fund its ADAP directly. The state operates an independent system that

provides outpatient HIV/AIDS drugs through hospitals to those in need. This system was funded

at $2 million in fiscal year 1995, $3.3 million in fiscal year 1996, and $20 million in fiscal year 1997.

Sources: National Alliance of State and Territorial AIDS Directors, The Fiscal Status of State AIDS

Drug Assistance Programs: Findings From a January 1996 National Survey of State AIDS

Directors (Washington, D.C.: Apr. 1996); National Alliance of State and Territorial AIDS Directors

and the AIDS Treatment Data Network, State AIDS Drug Assistance Programs: A National Status

Report on Access (Washington, D.C.: July 1997). and National ADAP Monitoring Project: Interim

Technical Report (Washington, D.C.: Mar. 1998).

Page 32 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix III 

EMA Contributions to ADAPs

Currently, 49 communities in 21 states, the District of Columbia, and

Puerto Rico have been designated under title I of the CARE Act as EMAs

disproportionately affected by the AIDS epidemic. In 1997, these EMAs

contributed some $24 million to the ADAP programs. The level of these

contributions has been generally flat over the past few years, increasing

from 1995 to 1996, and then declining slightly in 1997 (see table III.1).

Table III.1: Title I EMA Contributions to ADAPs and Percentage Change, Fiscal Years 1995, 1996, and 1997

Contribution amount Change, FY 1995-97

States with EMAs FY 1995 FY 1996 FY 1997 Amount Percentage

Arizona 0 0 $407,000 $407,000 a

California 0 0 0 0 0

Colorado $350,000 $261,000 774,749 424,749 121

Connecticut 209,500 421,500 443,892 234,392 112

District of Columbia 74,801 800,000 1,150,873 1,076,072 1,439

Florida 0 0 0 0 0

Georgia 365,420 1,064,645 1,000,000 634,580 174

Illinois 0 825,000 0 0 0

Louisiana 0 0 0 0 0

Maryland 123,581 453,963 330,394 206,813 167

Massachusetts 300,000 350,000 1,177,465 877,465 293

Michigan 187,500 400,000 300,000 112,500 60

Minnesota 0 0 0 0 0

Missouri 36,675 0 0 (–36,675) (–100)

New Hampshire 0 72,308 102,388 102,388 a

New Jersey 516,250 792,024 1,410,738 894,488 173

New York 17,591,280 19,858,730 16,043,941 (–1,547,339) (–9%)

Ohio 0 0 0 0 0

Oregon 0 0 537,000 $537,000 a

Pennsylvania 0 0 0 0 0

Puerto Rico 1,013,827 0 0 (–1,013,827) (–100)

Texas 0 217,000 0 0 0

Washington 58,654 342,500 575,000 516,346 880

Total $20,827,488 $25,858,670 $24,253,440 $3,425,952 16

aPercentage change cannot be calculated.

Page 33 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix IV 

State-by-State Profile of ADAPs

From January 1997 to July 1997, 39 states’ ADAPs experienced growth in the

number of clients served; 42 experienced increases in monthly

expenditures for the same period. Six states experienced a 50-percent or

greater increase in clients served. For example, clients served through

Delaware’s ADAP increased 327 percent—the greatest increase experienced

by a state; conversely, Mississippi saw a 56-percent decrease in clients

served. Only five states experienced minimal change (a less than 5-percent

increase or decrease). (See table IV.1.)

Table IV.1: Number of Clients Served by ADAPs and ADAP Expenditures, July 1996, January 1997, and July 1997

Clients served Expenditures

State July 96 Jan. 97 July 97

Percentage

change,

July 96-

July 97 July 96 Jan. 97 July 97

Percentage

change,

July 96-

July 97

Alabama 500 454 486 (–3%) $167,000 $222,779 $316,359 89

Alaska a 5 11 b a 3,319 7,614 b

Arizona 335 435 448 34 116,761 226,611 287,075 146

Arkansas 259 351 426 64 45,260 85,536 119,713 165

California 6,258 7,431 8,539 36 3,557,218 4,487,075 5,914,041 66

Colorado 379 a 534 41 161,598 a 296,516 83

Connecticut 334 634 519 55 188,563 385,320 367,286 95

Delaware 55 11 47 (–15) 29,900 4,243 20,240 (–32)

District of Columbia 543c a 312 (–43) 299,497c a a b

Florida 4,322 4,565 4,868 13 1,748,679 1,576,631 2,590,826 48

Georgia 922 662 1,041 13 308,400 274,126 307,949 0

Hawaii 60 84 104 73 45,730 55,642 67,680 48

Idaho 30 50 48 60 7,215 23,179 29,410 308

Illinois 1,303 1,203 1,319 1 769,232 733,251 763,364 (–1)

Indiana 217 252 280 29 88,738 107,287 185,903 109

Iowa 43 35 45 5 8,630 21,656 38,519 346

Kansas 86 90 110 28 40,524 60,192 75,560 87

Kentucky 113 161 191 69 45,071 89,979 101,519 125

Louisiana a 87 175 b a 32,910 64,872 b

Maine 65 45 52 (–20) 24,145 23,600 34,404 42

Maryland 243 409 493 103 130,234 285,859 402,426 209

Massachusetts 792 860 858 8 309,851 494,361 607,585 96

Michigan 177 212 259 46 124,568 166,109 206,785 66

Minnesota 203 198 201 (–1) 36,258 58,019 50,039 38

Mississippi 301 427 188 (–38) 26,174 157,642 100,809 285

(continued)

Page 34 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix IV 

State-by-State Profile of ADAPs

Clients served Expenditures

State July 96 Jan. 97 July 97

Percentage

change,

July 96-

July 97 July 96 Jan. 97 July 97

Percentage

change,

July 96-

July 97

Missouri a 294 371 b a 128,761 215,180 b

Montana 23 18 18 (–22) 17,600 18,000 19,500 11

Nebraska 57 62 85 47 17,054 26,773 46,081 170

Nevada 217 281 336 55 81,900 62,556 64,428 (–21)

New Hampshire 45 43 57 27 21,745 22,582 40,828 88

New Jersey 994 1,700 1,960 97 380,000 900,000 1,200,000 216

New Mexico 330 421 465 41 125,094 213,546 218,175 74

New York 4,859 6,422 7,595 56 3,313,519 5,199,838 6,838,895 106

North Carolina 268 342 470 75 161,861 205,320 415,241 157

North Dakota 15 15 12 (–20) 4,417 a a b

Ohio 323 449 596 85 136,220 207,286 430,264 216

Oklahoma 139 242 293 111 61,686 115,430 165,507 168

Oregon 90 103 91 1 46,100 56,000 27,104 (–41)

Pennsylvania 1,060 997 1,268 20 467,808 656,745 908,362 94

Puerto Rico 1,920 1,980 2,320 21 750,000 a a b

Rhode Island 69 89 140 103 16,216 30,170 60,000 270

South Carolina 149 198 310 108 68,220 127,113 215,606 216

South Dakota 25 19 17 (–32) 6,800 10,047 6,499 (–4)

Tennessee 113 155 145 28 43,694 60,042 64,502 48

Texas 1,910 2,727 3,215 68 587,289 1,188,790 1,571,340 168

Utah 47 79 95 102 24,736 52,718 68,089 175

Vermont 37 32 41 11 20,053 14,115 22,526 12

Virginia 583 1,437 1,189 104 45,424 369,310 545,000 1100

Washington 338 492 543 61 147,342 210,451 313,782 113

West Virginia 31 39 43 39 15,206 29,176 29,554 94

Wisconsin 133 156 202 52 66,966 87,074 150,576 125

Wyoming 56 53 63 12 1,500 a a b

Total 31,371 37,506 43,494 39 $14,907,699 $19,568,167 $26,593,535 78

Note: Expenditure totals may not add because of rounding.

aNot available.

bPercentage change cannot be calculated.

cAugust 1996 data.

Source: National Alliance of State and Territorial AIDS Directors, March 1998 and July 1997.

Page 35 GAO/HEHS-99-2 HIV/AIDS Drugs
Appendix IV 

State-by-State Profile of ADAPs

(108305) Page 36 GAO/HEHS-99-2 HIV/AIDS Drugs
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