HIV/AIDS patients' health care options thin in New Orleans
HIV/AIDS patients' health care options thin in New Orleans
July 19, 2010
By Aimee Miles
A state program designed to help low- and moderate-income HIV and AIDS patients pay for prescription drugs has had to turn away 177 qualified applicants since officials cut off enrollment June 1 in an effort to plug an $11.7 million budget shortfall.
The Louisiana AIDS Drug Assistance Program, which served 3,500 people last year, also has canceled several contracts with HIV clinics and community-based organizations that provide ambulatory and outpatient care, and it has reduced financing to several community clinics, forcing their directors to consider cutting legal aid, peer counseling, mental health and emergency food and cash assistance programs, said DeAnn Gruber, the interim administrative director of Louisiana's HIV/AIDS Program.
Those measures, however, have reduced the budget gap by only $4 million to $5 million. Unless they can find money elsewhere or manage further cuts in a program projected to cost $31.4 million through March 2011, state officials may be forced to shut down the drug program altogether by next spring, according to the state Office of Public Health.
The dire circumstances result from a confluence of factors, including dwindling federal financing for HIV and AIDS programs, rising drug costs, escalating poverty and the implementation of more proactive testing and treatment initiatives that have swollen the ranks of new HIV patients in Louisiana by 15 percent since 2008.
The New Orleans area -- which ranks third in the nation, after Miami and Baton Rouge, in new AIDS cases and eighth in the percentage of residents living with AIDS -- stands to be hit particularly hard, advocates say.
Meanwhile, President Barack Obama last week unveiled a first-ever national AIDS strategy, including a $26 billion request for HIV- and AIDS-related programs for the 2011 fiscal year.
Topping the agenda is increasing HIV testing while reducing the HIV transmission rate. Together, the steps are aimed at shrinking the rate of new HIV infections by 25 percent by 2015.
Local advocates say the program's ambitious goals mirror strategies already under way in Louisiana, including a recent push to target at-risk communities and increase coordination among local care providers.
But they also warn that efforts to identify HIV-positive patients and secure their long-term care can result in larger case loads -- and ballooning price tags -- for local health care providers.
"It's very ambitious to say, 'In five years we want to reduce new infections by 25 percent,' " Gruber said. "We feel that some of these things are definitely achievable, but we also need the dollars tied to it."
Poverty at root
In the New Orleans area, which includes Metairie and Kenner, about 3,700 of 807,000 residents currently live with AIDS, with another 2,000 people estimated to be infected with HIV, according to the Louisiana Office of Public Health.
Experts attribute the high rates in the region, as well as in Baton Rouge, to widespread poverty, which underlies more direct causes, such as lack of education, poor access to health care and the prevalence of other sexually transmitted diseases, known as co-infections, that increase the risk of contracting HIV.
"For many people in the community, health care is not a priority," said Noel Twilbeck, who directs the NO/AIDS Task Force, a New Orleans nonprofit group that provides health care services. "They're dealing with other things. Housing, loss of jobs, family members, co-infections and psychosocial things are going on in their lives that are keeping people from getting into health care."
Also contributing to growing patient rosters are the growing quality and availability of medicine, including drugs provided through the state's AIDS Drug Assistance Program, known as ADAP.
"Because of increasingly better medications, people are living with HIV, " Twilbeck said.
Statewide, more than two-thirds of new HIV cases are men, and almost 75 percent are African-Americans, although black residents comprise only 33 percent of the state's population. Sexual intercourse between men and injection drug use are among the most common modes of transmission.
Need outpaces funding
A federal program financed in part by the Ryan White HIV/AIDS Program, ADAP was designed to throw a lifeline to uninsured individuals who met financial eligibility criteria as determined by individual states. It was to be a safety net for people with the disease who didn't qualify for Medicare, Medicaid or other public health programs.
To qualify for ADAP assistance in Louisiana, a person's annual income cannot exceed 300 percent of the federal poverty level, which is $10,830 a year for an individual or $22,050 a year for a family of four. More than 3,500 Louisianians used the program in 2009.
Twelve other states also have capped their ADAP enrollment to contain rising costs, but the enrollment cutoff will be felt deeply in Louisiana, where 56 percent of people have incomes below 300 percent of the federal poverty level and 19 percent of the population is uninsured.
The affected states collectively applied for $126 million in additional federal money to keep their respective programs afloat for another year, but they received a total of only $25 million.
ADAP's troubles are symptomatic of a larger financial crisis that is putting a strain on state, regional and community-based HIV/AIDS organizations, all of which are at least partially dependent on the Ryan White Program to sustain their services.
Of the five federal programs that finance states' HIV/AIDS programs, the Ryan White Program is by far the largest. It provided Louisiana with $45 million -- more than 75 percent of the state's HIV/AIDS budget -- in 2008. The program relies on annual congressional appropriations, which have remained fairly constant in recent years despite the rising cost of care and the growing number of people who need it.
'Divvying up dollars'
AIDS service leaders have long bemoaned the structure of the Ryan White Program, which allocates money separately to states, cities, public and private providers, and community-based organizations. Originally intended to prevent the "silo effect" of overlapping resource allocation, the rigid division of funds is increasingly burdensome to Louisiana administrators.
New Orleans, for example, is considered an "eligible metropolitan area" under the Ryan White Act, which means the city receives a separate allocation from the rest of the state, except for ADAP money, which is appropriated to the state but can be accessed by New Orleans residents who qualify.
Although New Orleans residents with HIV have access to more than one money stream in the Ryan White Program, those living in Houma, who often are serviced by New Orleans-based organizations, aren't eligible for the same level of financial assistance.
Twilbeck said he has seen those disparities between cities throughout the United States.
"The equations for divvying up dollars are based on AIDS case rates," he said.
But in the absence of up-to-date data, states often have reported the cumulative number of people diagnosed with HIV or AIDS since the state first began assembling data, not the number of people currently living with the disease.
Those inconsistencies haven't worked to Louisiana's advantage. Because the state began confidential name-based reporting of HIV and AIDS cases in the early 1980s, meaning it has good up-to-date data, it hasn't seen the same level of federal aid -- in proportion to the size of the infected population -- as some other states.
Going straight to the source
Because Louisiana's ADAP program isn't expected to start enrolling new patients anytime soon, the state is encouraging would-be applicants to appeal instead to pharmaceutical companies' patient assistance programs -- which provide medications at reduced or no cost -- to get the life-sustaining drugs they need.
Although the financial eligibility criteria for other patient assistance programs in Louisiana are the same as they are for ADAP, processing the applications takes time, and patients have to apply for each drug separately. They often are dealing with several different pharmaceutical companies at simultaneously.
"That process is very cumbersome," said Twilbeck. "If you're on five different medications and five different application processes, the timing doesn't necessarily sync. You might get approval for one (now), next week another, and the medications should all be taken together."
Ryan White Program case managers and other staff members from community organizations and LSU Health Sciences Center have stepped in to help with the application process, which usually takes about two weeks.
Alana Moore, a medication assistance program specialist who works with the NO/AIDS Task Force, said she has not yet seen an eligible person turned away by a pharmaceutical company.