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Rapid tests could mean trouble for ADAPS
Increased HIV testing could flood system
As if AIDS Drug Assistance Program (ADAP) directors and other people monitoring the costs of providing HIV drugs to the uninsured weren’t worried enough, they have a new potential problem to discuss: How would t he states and ADAP programs handle a large influx of new HIV and AIDS patients if the Centers for Disease Control and Prevention (CDC) succeeds in significantly increasing HIV testing rates?
With estimates of some 200,000 to 300,000 people in the United States who are HIV-positive and don’t know it, a big increase in HIV testing could put a whole lot more HIV-infected people into the ADAP and Medicaid care systems, says Murray Penner, director of the HIV Treatment Program of the National Alliance of State and Territorial AIDS Directors of Washington, DC.
"It’s going to be a huge strain on the program, and we’re already experiencing waiting lists, so it absolutely is a big concern," he says.
Push could add thousands of clients
The new push for HIV testing and outreach using the rapid HIV test could result in 5,000 to 15,000 new AIDS clients being added to the ADAP rolls, says Bill Arnold, director of the ADAP Working Group in Washington, DC.
It’s a safe bet that most of the HIV-positive people discovered through increased testing and counseling outreach programs will not be people who have adequate health insurance to cover their antiretroviral medications, he says.
"The outreach vans are going into areas where nobody goes to see a doctor unless their health is so bad that they have to go to the emergency room," Arnold adds.
"We had in Washington, DC, a grandmother who was so busy taking care of her kids and grandkids that by the time she ended up in an emergency room, she had full-blown AIDS; and at the age of 61, she died of PCP [Pneumocystis carinii pneumonia]," he adds.
These are the kinds of cases that rapid testing might uncover. And while that is a positive public health direction, the big question is whether ADAPs and other safety nets will be able to handle an influx of such new clients.
The key will be how quickly and in what regions these new cases show up, Arnold contends. "If they all come out in 60 days — then we’re screwed."
Likewise, if a disproportionate number of these new cases appear in states that have struggled all year with ADAP funding, including Texas, North Carolina, and Alabama, then those ADAPs likely will have serious problems meeting the increased need, he says. "We’re trying to figure out what we should be preparing for."
By late summer, the number of people on ADAP waiting lists had grown to more than 600, and 16 states had limited access to antiretrovirals.
New York and California seemed to be handling their ADAP and Medicaid clients with HIV, but a budget and political crisis in California could threaten that stability; and no one could say whether these states could handle a large influx of new HIV cases discovered through rapid testing and outreach programs, Arnold points out.
Throw on top of this the ubiquitous state fiscal problems and Medicaid cuts that are throwing more people onto the ADAP rolls, and there is serious cause for concern, Penner explains.
"And this doesn’t look any better with Fiscal Year 2004 funding, which is actually less [of an increase] than what it was last year," he points out.
Congress to the rescue?
Penner and Arnold held out hope that Congress would come through with emergency funding or at least increase the amount promised for next year’s ADAP budget and that Congress would pass the Early Treatment for HIV Act, which was introduced last June.
"There has to be long-term solutions, including having expanded Medicaid coverage like the Early Treatment for HIV Act," Penner says. "This would allow people to get on Medicaid much sooner in their disease process and allow them to receive antiretrovirals, which would take some strain off of ADAP."
Also, there were two pieces of good news this year for ADAP, and these will help a little with the crisis, Arnold says.
The first is that all of the major antiretroviral manufacturers agreed to stabilizing prices of HIV drugs through voluntary rebates and other price-cutting concessions to last through the next 1½ years, he says.
The other good news is that the ADAPs which included the new infusion therapy in their formularies have not had the expected influx of clients needing this expensive new treatment, Arnold says.
"The take-up rate with ADAPs has been much slower than people thought," he says. "So that’s good news, but how long that will go on, we don’t know."