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Shortening the life line 

A program to provide financial help for those seeking expensive treatment for AIDS and HIV has recently seen its income eligibility threshold slashed by more than half, leaving many of those who depend on the program scrambling for other options.

The Arkansas Drug Assistance Program, or ADAP, was started in 1990 by the Arkansas Department of Health to assist AIDS and HIV patients in paying for their medications, which can routinely top $1,000 a month. ADAP is a partner of the state's Ryan White Comprehensive AIDS Resource Emergency (CARE) program, which provides AIDS/HIV patients help with insurance co-pays, oral health, transportation to and from medical appointments and other expenses. Approved by Congress in 1990 after the death of Indiana teen-ager Ryan White, who contracted the disease while being treated for hemophilia, the programs are funded by a federal grant.

Since 2007, the ADAP and CARE programs have offered help to accepted applicants whose yearly income was up to 500 percent of the federal poverty level — $51,050 or less. Beginning on May 22, however, the Health Department reduced the eligibility threshold to 200 percent of the poverty level — $21,660.

Health Department officials said they had to reduce the threshold to make room for the increasing number of people in the most desperate financial situations. As more Arkansans with AIDS/HIV have lost their jobs and health insurance, ADAP and CARE have seen a spike in patients seeking assistance. Because the federal grant for CARE and ADAP is fixed and the programs must admit applicants who meet medical and economic eligibility requirements, officials feared the programs would have eventually been overwhelmed financially if the threshold had not been lowered.

Under the new guidelines, 203 patients currently enrolled in the CARE program will be removed from the rolls, as will 49 people currently served by ADAP.

Kevin Dedner, the Health Department's section chief for AIDS, STDs and Hepatitis C, said that there are 698 patients enrolled in ADAP now. “Our earmark is around $4.1 million for ADAP,” Dedner said, “which means we can comfortably support about 402 persons on the drug assistance program. You can see the stark difference between 402 and 698.”

The ADAP grant has also shrunk, by around $600,000 from the previous fiscal year.

The income eligibility threshold wasn't always 500 percent. Prior to 2005, eligibility was limited to those making 300 percent of the federal poverty level. That changed when federal law reauthorizing the program in 2006 provided a significant bump in funding.

“In May of 2007,” said Gail Gannaway, associate branch chief for infectious diseases, “we increased our eligibility level because we had significantly more money to spend.”

James Phillips, infectious disease chief said that in fiscal year 2006, “We had a 2 percent increase [in ADAP enrollment]. 2007 to 2008, there was a 22 percent increase in enrollment, and 2008 to 2009 there was a 54 percent increase in enrollment. So you can see where the problem arises.”

Dr. Michael Cannon, executive director of the non-profit Arkansas AIDS Foundation, said that his organization sent out letters two weeks ago reminding their clients about the change. “There are other alternative methods, but [patients are] going to have to be a little more industrious at this point,” Cannon said. “It's not like we won't assist them, but there's just no more money for a handout.”

Gannaway said that patients who are already enrolled in the ADAP and CARE programs but exceed the income threshold have been “grandfathered in” and given until Dec. 31 to make other arrangements for their care. In that time, patients are being encouraged to apply for patient assistance programs set up by pharmaceutical companies to provide help in purchasing drugs. “You might imagine that at the price they're getting for these [drugs], there would be a lot of protest,” Phillips said. “That why the pharmaceutical companies are somewhat eager to assist in these patient assistance programs, so there won't be a major uproar.”

Dedner said the Health Department is working to help people complete the paperwork for the pharmaceutical company programs — a process which can take up to six weeks. His department has also started a list for those seeking financial help with their drugs, something that is crucial if the programs are to receive emergency funding. “Having the waiting list puts us in a position that we can go after supplemental funding in January,” Dedner said. “However, the supplemental funding is a competitive process. It's not something that's guaranteed for the state, but we will make every effort to try to bring in more dollars.”

Phillips said he's concerned that the difficulty of the paperwork required for applying for help from pharmaceutical companies will discourage patients from filing and they will end up going without medication. Once a patient strays from the treatment regimen for HIV/AIDS, restarting treatment can be complicated and even more expensive. “Continuity is very important in decreasing the development of resistance,” Phillips said. “Once an individual develops a resistance to the first set of drugs that they are started on, then you try to recoup and progress onto a different regimen. It almost always is a more expensive regimen.”

Behind the scenes, Dedner said, the department is working to cut costs, and doing all it can to help patients cope with the change. “We've been working on cost containment measures for a few weeks,” he said. “We took a hard look at our formulary and actually removed some drugs from our formulary to reduce costs … so we've done a lot of things to try and avoid this point.”

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