Florida’s recent decision to dramatically restrict eligibility for its AIDS Drug Assistance Program (ADAP) and remove a widely prescribed antiretroviral medication, Biktarvy, from its formulary, signals a growing trend of cost-containment measures impacting HIV care across the United States. The changes, which would reduce income eligibility from 400% to 130% of the federal poverty level, have sparked legal challenges and raised concerns about access to treatment for people living with HIV.
The move in Florida is not isolated. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicates that 23 states, including Washington, D.C., have implemented or are considering similar ADAP cost-containment measures. Eighteen states have already made changes, while five others are contemplating future adjustments. These measures include reducing income eligibility, limiting formularies, decreasing funding for medical and support services, and tightening recertification requirements.
ADAPs are a critical component of the Ryan White HIV/AIDS Program, the largest federal program specifically designed for people with HIV. Established in 1990, the program provides a safety net for those without health insurance or with limited coverage. The Ryan White program serves over half of all people diagnosed with HIV in the U.S., providing outpatient HIV care, treatment, and essential support services. In fiscal year 2024, the program received $2.6 billion in funding, including support for the “Ending the HIV Epidemic” (EHE) initiative.
However, funding has not kept pace with increasing needs. Since 2005, inflation-adjusted appropriations for ADAPs have declined by 31%, largely due to a decade of flat funding in nominal dollars. According to NASTAD, growing client enrollment, rising drug costs, and increasing insurance costs are the top three drivers of budget concerns. The number of ADAP clients served increased by 56% between 2007 and 2024, rising from 165,382 to 257,644.
The cost of HIV medications is also a significant factor. The average wholesale price of recommended antiretroviral regimens increased from roughly $25,000 to $35,000 in 2012 to $36,000 to $48,000 in 2018, and has continued to rise. Biktarvy, the most widely prescribed antiretroviral medication in the U.S., accounting for 52% of the market, had an average wholesale price of $61,000 in 2025. While ADAPs benefit from price discounts through the 340B drug pricing program and manufacturer rebates, increasing drug prices remain a concern.
Adding to the financial strain, the expiration of enhanced Affordable Care Act (ACA) premium tax credits is increasing insurance costs for many. These credits, which helped make marketplace plans more affordable, expired at the end of 2025 due to a lack of Congressional agreement to extend them. The expiration is estimated to more than double premiums for subsidized enrollees, increasing the average annual cost from $888 in 2025 to $1,904 in 2026.
States are responding to these pressures in various ways. In addition to Florida, Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their ADAP programs. Some states are exploring reducing formularies, decreasing funding for medical and support services, and implementing stricter recertification processes. Arkansas, Louisiana, and New Jersey are even considering implementing waiting lists, a measure widely considered a last resort.
The changes in Florida have faced legal opposition. Advocates, patients, and providers sued the state for proceeding with the changes without formal rulemaking. While the state subsequently issued a proposed rule and followed with emergency rulemaking, litigation continues to challenge the implementation of the new policies.
The potential consequences of these cost-containment measures are significant. Limiting access to Ryan White services could lead to people with HIV losing access to care and treatment, potentially worsening health outcomes and increasing the risk of new HIV infections. Experts note that four in ten new HIV transmissions are linked to individuals aware of their HIV status but not currently receiving care.
