Longitudinal national surveys reflect steady challenges for AIDS drug assistance programs, 2017-2024

As part of the Ryan White HIV/AIDS Program, AIDS Drug Assistance Programs (ADAPs) provide HIV medications and insurance assistance to low-income people with HIV across all U. S. states, the District of Columbia, and territories. The share of clients receiving insurance assistance through ADAPs has grown considerably, particularly following the Affordable Care Act (ACA), requiring ADAPs to coordinate with an increasingly complex array of public and private payers. This is the first study to examine longitudinal trends in the challenges ADAPs report. We conducted a descriptive analysis of the challenges reported by ADAPs between 2017 and 2024 in the NASTAD National ADAP Monitoring Project Annual Reports. ADAP leaders rated seven insurance-related domains (2017-2024) and 10 general program domains (2021-2024) as Not, Somewhat, and Very Challenging. We categorized responses as "Not Challenging" or "Challenging" (Somewhat/Very). Between 46 and 51 ADAPs responded annually. Although the overall number of domains rated as challenging decreased over time, six were rated as challenging by >50% of ADAPs in every year assessed: mail order pharmacy limitations, client churn, high copay/coinsurance, maintenance of eligibility, IT and data-sharing issues, and staff turnover. Some challenges increased, including pharmacy network issues (15 to 27%; +12 percentage points, +78% relative), while others declined, including remote work (37 to 10%; -27 percentage points, -72% relative). Despite a modest overall decrease in reported challenges, insurance coordination and core-operational challenges persisted across the years assessed. Continued monitoring may be particularly important as anticipated Medicaid and Marketplace changes take effect.