When Cuts Cost More: Projected Fiscal Impact of Eliminating the AIDS Drug Assistance Program in 30 US States
- 1Johns Hopkins Bloomberg School of Public Health
Abstract
BackgroundThe AIDS Drug Assistance Program (ADAP) supports antiretroviral therapy for low-income people with HIV. We assessed whether ADAP savings would offset additional HIV care costs resulting from new infections.
MethodsUsing the Joint HIV Epidemiologic and Economic Model calibrated to 30 US states and the District of Columbia, we compared continued 2025 ADAP coverage with elimination beginning Jan-2026. We projected excess HIV infections and care costs through 2035 under three cost-scenarios. Projected costs were limited to HIV care costs attributable to excess incident infections that would results from eliminating ADAP. The primary outcome was the Net Cost to Expenditure Ratio (NCER), defined as healthcare-system costs minus ADAP expenditure, relative to ADAP expenditure by 2035.
ResultsAcross the modeled US jurisdictions, ADAP elimination was projected to result in a median of 143,347 additional HIV incident cases, generating $11.24 billion in HIV care costs through 2035. Compared with $6.58 billion in ADAP spending, this resulted in $4.66 billion in net additional costs (NCER=0.71). For every $1 in ADAP spending avoided, the healthcare system incurred $1.71 in downstream HIV care costs, a net increase of $0.71. This pattern was strongest in states with high baseline ADAP coverage and more rural HIV populations, many of which were Medicaid non-expansion states in the South, with substantial variation in NCER across jurisdictions (3.79 in Missouri to -0.97 in the District of Columbia).
ConclusionsEliminating ADAP would be medically and fiscally counterproductive, increasing HIV burden and generating healthcare costs that would exceed program savings within seven years.
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BibTeX
@misc{forster2026when,
title = {{When Cuts Cost More: Projected Fiscal Impact of Eliminating the AIDS Drug Assistance Program in 30 US States}},
author = {R. M. Forster and M. Schnure and R. Balasubramanian and J. L. Jones and E. P. Hyle and S. Batey and K. N. Althoff and K. Gebo and D. Dowdy and M. Shah and A. T. Fojo and P. Kasaie},
howpublished = {medRxiv},
year = {2026},
month = jul,
doi = {10.64898/2026.07.27.26359045},
url = {https://www.medrxiv.org/content/10.64898/2026.07.27.26359045v4},
note = {CC BY},
}
RIS
TY - UNPB
TI - When Cuts Cost More: Projected Fiscal Impact of Eliminating the AIDS Drug Assistance Program in 30 US States
AU - R. M. Forster
AU - M. Schnure
AU - R. Balasubramanian
AU - J. L. Jones
AU - E. P. Hyle
AU - S. Batey
AU - K. N. Althoff
AU - K. Gebo
AU - D. Dowdy
AU - M. Shah
AU - A. T. Fojo
AU - P. Kasaie
PY - 2026
DA - 2026/07/27
PB - medRxiv
DO - 10.64898/2026.07.27.26359045
UR - https://www.medrxiv.org/content/10.64898/2026.07.27.26359045v4
AB - BackgroundThe AIDS Drug Assistance Program (ADAP) supports antiretroviral therapy for low-income people with HIV. We assessed whether ADAP savings would offset additional HIV care costs resulting from new infections. MethodsUsing the Joint HIV Epidemiologic and Economic Model calibrated to 30 US states and the District of Columbia, we compared continued 2025 ADAP coverage with elimination beginning Jan-2026. We projected excess HIV infections and care costs through 2035 under three cost-scenarios. Projected costs were limited to HIV care costs attributable to excess incident infections that would results from eliminating ADAP. The primary outcome was the Net Cost to Expenditure Ratio (NCER), defined as healthcare-system costs minus ADAP expenditure, relative to ADAP expenditure by 2035. ResultsAcross the modeled US jurisdictions, ADAP elimination was projected to result in a median of 143,347 additional HIV incident cases, generating $11.24 billion in HIV care costs through 2035. Compared with $6.58 billion in ADAP spending, this resulted in $4.66 billion in net additional costs (NCER=0.71). For every $1 in ADAP spending avoided, the healthcare system incurred $1.71 in downstream HIV care costs, a net increase of $0.71. This pattern was strongest in states with high baseline ADAP coverage and more rural HIV populations, many of which were Medicaid non-expansion states in the South, with substantial variation in NCER across jurisdictions (3.79 in Missouri to -0.97 in the District of Columbia). ConclusionsEliminating ADAP would be medically and fiscally counterproductive, increasing HIV burden and generating healthcare costs that would exceed program savings within seven years.
ER -