Although the CARE Act is designed specifically for people with HIV disease, clients face challenges in accessing CARE Act services. Access to life-extending comprehensive antiretroviral therapy and primary care, for example, varies significantly by state and city of residence (Table 4-2). In North Carolina, people with HIV and incomes up to 125 percent of the federal poverty level (FPL) are eligible for ADAP services, while residents in New Jersey may qualify with incomes up to 500 percent of the FPL. Other states have specific income eligibility limits, such as less than $50,000 in Massachusetts and less than $30,000 in Pennsylvania (Kates, 2004).

Primary care access may vary from city to city and state to state depending on planning council and state funding allocations. Likewise, substantial state variation occurs in the types of drugs covered, the number of prescriptions provided through ADAP, and the capacity of the ADAP program to assist individuals who need HAART. States such as Louisiana, Nebraska, and Utah provide access to fewer than 20 drugs. Other states—including New York (463 drugs), Missouri (270), Connecticut (170), and California (144)—provide access to a larger number of drugs through their ADAP formularies, while Massachusetts and New Jersey have open or unrestricted ADAP formularies.

Limitations in ADAP formularies may have important health consequences. The care of HIV disease often requires numerous medications for complicating conditions or symptoms, in addition to antiretroviral drugs. Ceilings on the number and type of prescription drugs allowed may force dangerous choices concerning this essential element of care. With antiretroviral drugs, effective continuation of clinical benefit often requires replacing drugs in the regimen because of complex patterns of resistance and intolerance. Optimum outcome can be seriously compromised if the provider is limited in choosing among these crucial drugs because delays in controlling viral growth can allow rapid resistance and, ultimately, clinical failure.

The number of people living with HIV/AIDS continues to grow, as does the cost of care and the demand for CARE Act services. As a discretionary grant program, the CARE Act depends on annual appropriations by Congress (and often by states and municipalities). CARE Act dollars do not necessarily match the need for services, and many grantees have been unable to serve all those in need. This is a particular problem for ADAP. In June 2003, many Ryan White-funded ADAP programs reported budget shortfalls and had to develop or implement plans to restrict access through waiting lists (nine states) or caps on enrollment (four states) and/or limit benefits available to individuals already in the program (three states) (NASTAD, 2003).

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