Monday, July 5, 2010

ADAP Mishap: Who will have access to HIV medications in this economy?

I recently saw an article in the New York Times which nicely summarized the problem we've been discussing at my office for at least two months. The article inspired me to post a few more details of this tragic budget shortfall. ADAP (AIDS Drug Assistance Program) is the federal program which provides HIV medications at no cost to those in our society who cannot afford them.

Who can afford HIV medications? HIV medications cost roughly $12,000 a year per person. Most Americans cannot afford that. Someone who has medical insurance through their job might have to pay hundreds of dollars in copays each month. Someone insured through Medicare will meet a gap in medication coverage every year - meaning even Medicare cannot afford to cover it's HIV positive client's medication costs. Some Medicare clients may qualify for (LIS)Low Income Subsidy which offers extra help in covering the cost, but not all Medicare clients qualify and have to turn to other programs (like ADAP) to carry them through the rest of the year. Until now, ADAP has been the program the uninsured and underinsured have turned to, to provide them with the drugs they need to survive.

The article, coincidentally, addresses the problem in both Louisiana and Florida - the two states I care the most about. Florida now has a waiting list for ADAP. The grim fact about waiting lists are that a patient will either have to win the lottery and become rich enough to buy their own meds or they will have to die for someone else to take their place in the program. Louisiana, on the other hand, refuses to have an official waiting list. As I have heard before and is quoted in the article:
“It implies you’re actually waiting on something,” said DeAnn Gruber, the interim director of the state’s H.I.V./AIDS program. “We don’t want to give anyone false hope.”

One alternative to ADAP are the drug companies themselves. Most HIV drugs are offered through "Patient Assistance Programs." Meaning, the drug companies create their own eligibility requirements and some patients will be able to get their meds for free or at reduced cost. And some will not.

As a
bilingual case manager, I am concerned about what this means for undocumented patients. ADAP was the program many undocumented patients used because they often hold jobs that do not offer insurance, and they do not qualify for Medicare. Citizenship is not a requirement for ADAP. But citizenship, or at least legal residence is a requirement for many of the patient assistance programs. In meetings, we have actually discussed the reality that doctors will have to consider their patients' legal status when prescribing HIV medications.

The idea that doctors will have to consider such political factors as citizenship, visas and passports when prescribing medication is shocking enough. But for HIV medications, this is especially problematic. There are only between 20 and 30 different drugs to choose from. Patients are usually prescribed three at a time, to better fight the virus and to prevent resistance. Resistance is a huge issue with HIV medications. The virus is very clever. Attacking it with three medications at a time is the breakthrough that has allowed HIV positive people to lead longer, healthier lives in our lifetime. Tests are often run before prescribing HIV medications to see if any resistance has already developed in a patient. Doctors are already limited by resistance profiles and contraindications - from the patient's other health conditions - when prescribing medication. We should anticipate that there will be patients who are resistant to the medications they can afford, and too poor for the medications they need.

With ADAP closing it's doors and directing patients to ask the drug companies for help, there will be people who fall through the cracks. There will be patients who do not get the drugs they need because they are undocumented immigrants.

* I have seen comments online from people who are aghast that the government pays for these medications at all. It's true that medications for cancer, diabetes and heart disease are not covered by the government in the same way that HIV medications are. There is a reason for that. Unlike chronic, non-infectious diseases, HIV spreads. People on anti-retroviral treatment are less likely to pass the virus on to others. They are healthier, live longer, higher quality lives - they can better contribute to society, the economy, take care of their children. HIV is different from other major diseases in that it attacks people in the middle of life, when they are parents, when they have careers. These drugs are important, not only to the people who take them, but to our communities, to families, to our society as a whole.

1 comment:

Digwan said...

Nicely put! From a public policy perspective I see all this stuff as a balance sheet. I politicians de-fund a social program such as ADAP then other costs arise (more new HIV cases with all associated medical, service, and social costs; orphaned children into foster care at state expense; lost economic productivity; increased utilization of emergency rooms and other services and so on). There are no savings, just delaying costs or moving costs from one column to another...
Thanks for your blog!