In addition to funding primary and specialty care, the federal, state, and sometimes local governments, as well as foundations, charitable agencies, and other groups, allocate funds exclusively to provide HIV- and AIDS-related care to women and children. The most important source of federal funding for HIV/AIDS care is the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, administered by HRSA's HIV/AIDS Bureau. In addition, CDC supports community programs.
Under the Ryan White CARE Act, funds are awarded to eligible metropolitan areas under Title I to provide outpatient health care, support services, and inpatient case management. Title II funds go to states for homeand community-based health care and support services, continuation of health insurance coverage, and drug treatment through the AIDS Drug Assistance Program (ADAP). Title III provides funds to community agencies for early intervention services. Title IV funds community-based agencies for coordinated HIV services and access to research for children, youth, women, and families, and funds a smaller program that focuses specifically on reducing perinatal HIV transmission. Title V funds a dental reimbursement program, education and training centers, and demonstration projects that address hard-to-reach populations.
A major source of concern for HIV/AIDS patients and their providers is the cost of the drugs used for treatment. Many private insurance polices cover these medications. Medicaid also covers pharmaceuticals, but may impose limits. The ADAP, operating under Title II of the Ryan White CARE Act, is the second largest source of funding for HIV/AIDS drugs after Medicaid and is the payment of "last resort" (i.e., ADAP funds may be used only after all other public and private insurance sources have been exhausted). The program provides funds to all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam to make protease inhibitors and other therapies available to the uninsured and underinsured individuals with HIV. Administered by the state AIDS directors, each state determines its own financial and medical eligibility criteria, the type and number of drugs covered, and their purchase and distribution.
The demand for ADAP funds has increased dramatically as the number of persons with HIV has grown and new therapeutic regimens have been developed. In 1996, 83,000 persons with HIV disease were served and $52 million in supplemental funds were appropriated to supplement the $53 million committed by states from their Title II awards. The FY 1997 ADAP budget had a 221% increase over FY 1996, with the majority of funds coming from federal sources (Doyle et al., 1997). Fifteen states have waiting lists for ADAP enrollment and/or for access to protease inhibitors (AIDS Policy Center for Children, Youth and Families, 1998). In 1997, four state programs did not cover protease inhibitors and two states covered only one. Five states did not cover any of the prophylactic drugs