State HIV Programs Face Budget Cuts, Limiting Access to Care & Treatment

The nation’s HIV safety net is facing strain, as constrained state budgets lead to restrictions in access to essential medications and services for people living with HIV. Several states are implementing cost-containment measures within the Ryan White HIV/AIDS Program, the largest federal program dedicated to HIV care, raising concerns about potential disruptions in treatment and a possible reversal of progress in controlling the epidemic.

State ADAPs Respond to Financial Pressures

The Ryan White program provides a critical lifeline for individuals with HIV who lack adequate health insurance or face limitations in their coverage. A key component of the program are AIDS Drug Assistance Programs (ADAPs), which help cover the cost of HIV medications and, in some cases, health insurance premiums. However, funding for ADAPs has not kept pace with rising drug costs, increasing enrollment, and, more recently, escalating insurance premiums. This financial pressure is forcing states to make difficult choices.

Florida has recently announced significant changes to its ADAP, dramatically limiting eligibility and the scope of assistance provided. The state plans to reduce income eligibility from 400% of the federal poverty level (FPL) to 130% FPL, a substantial decrease that would exclude many individuals currently receiving assistance. For an individual, this translates to a drop in maximum income eligibility from $63,840 to $20,748 annually.

Beyond eligibility restrictions, Florida is also removing Biktarvy, the most widely prescribed antiretroviral medication in the U.S. (accounting for 52% of the market), from its formulary. Biktarvy is a single-tablet regimen recommended by national HIV treatment guidelines, and studies have shown that such regimens improve adherence by simplifying medication schedules. Improved adherence is crucial for maintaining viral suppression and preventing drug resistance.

The state is also rolling back its insurance assistance program, which further limits access to comprehensive care. As the expiration of enhanced Affordable Care Act premium tax credits drives up insurance costs, this reduction in assistance could leave many individuals unable to afford coverage.

These changes in Florida have sparked significant backlash from advocates, patients, and providers, and the state was sued for proceeding without formal rulemaking. While the state has since issued proposed and emergency rules, litigation continues to challenge the implementation of these changes.

A Broader Trend Across States

Florida is not an isolated case. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicate that 24 states (including Washington, D.C.) have implemented or are considering ADAP cost-containment measures. Nineteen states have already made changes, and five more are contemplating future actions. The NASTAD report details a range of measures being considered, including reducing income eligibility (as in Pennsylvania, Kansas, Delaware, and Rhode Island), reducing formularies, decreasing funding for medical and support services, and implementing stricter recertification requirements.

Notably, no state has yet implemented waiting lists for ADAP assistance, a measure previously used during periods of funding shortages but cleared with emergency federal funding in 2013. However, Arkansas, Louisiana, and New Jersey are reportedly considering this option as a future cost-containment strategy.

Underlying Factors Contributing to Budget Shortfalls

Several factors are converging to create these budgetary challenges for ADAPs. Federal ADAP funding has not kept pace with inflation since 2005, declining by 31% in adjusted dollars. The FY25 appropriation of $438.8 million has similar purchasing power to the program’s FY1999 funding level. This stagnation in funding coincides with a 56% increase in the number of ADAP clients served between 2007 and 2024, rising from 165,382 to 257,644.

Rising HIV drug costs are also a significant concern. The average wholesale price of recommended antiretroviral regimens has increased substantially over the past two decades. While ADAPs benefit from price discounts through the 340B drug pricing program, these discounts may not fully offset the increasing costs. The AWP for Biktarvy was $61,000 in 2025, and other recommended regimens range from $34,320 to $65,196. These costs are detailed in national HIV treatment guidelines.

Finally, the expiration of enhanced Affordable Care Act premium tax credits is exacerbating the problem. These credits helped make insurance more affordable for many individuals with HIV, but their expiration is leading to significant premium increases, particularly for those with incomes above 400% FPL.

Potential Consequences and What Comes Next

These cost-containment measures could have serious consequences for people living with HIV. Limiting access to medications and care could lead to worsened health outcomes, increased morbidity and mortality, and potentially a rise in new HIV infections. Studies have shown that four in ten new HIV transmissions are associated with individuals who are aware of their HIV status but not consistently engaged in care.

The situation is evolving rapidly, and ongoing monitoring is crucial. NASTAD continues to track ADAP funding and cost-containment measures across states. Advocates are working to raise awareness of these challenges and advocate for increased funding for the Ryan White program. The future of HIV care access will depend on sustained advocacy, innovative funding solutions, and a commitment to ensuring that all individuals living with HIV have access to the treatment and support they need.

Looking ahead, the program will likely require ongoing evaluation of funding models and service delivery strategies to address the evolving needs of the HIV population. Continued attention to drug pricing and insurance affordability will also be essential to maintaining access to care.