Financial inhibitors.

Last issue The Advocate explained why protease inhibitors don't work for everybody. In most cases, however, patients do see success--as long as they can afford the drug. Now we examine ADAP, a federal program intended to help the uninsured get the medicines they need. Sometimes there's not enough for everyone. Next issue: How the prospect of living affects relationships that HIV-positive people are in.

Time was when doctors diagnosed patients HIV-positive, they prescribed sympathy. It didn't help much, but it came cheap. These days, diagnosis usually comes with potent protease inhibitors, capable of reducing the virus to undetectable levels in some people. The price of such good news: as much as $15,000 a year,

Missing a single dose of the drugs can weaken their power, increasing the virus's resistance. Yet thousands of people in Arizona may soon be off their prescription schedules because the state doesn't have enough money to pay for the medicine. "It's a gut-wrenching problem with no final solution at this time, says Peter Houle, executive director of AIDS Project Arizona. "It's one of the heaviest thoughts on my mind."

Arizona suffers a $1.2-million red mark in its AIDS Drug Assistance Program, federal help designed to provide drugs to uninsured HIV patients. Arizona is not the only state facing an empty coffee can. In May, Mississippi temporarily threw 600 people off ADAP because the program ran dry. In Alabama the program is closed to new patients. Like all AIDS programs conceived before the introduction of the new treatment, ADAP worked on the assumption that death would shrink the number of clients. "In the last two or three months, if your infection was bad enough, you ran up a $20,000 bill and than conveniently you were dead," says William Arnold, cochair of the ADAP Working Group, a coalition of pharmaceutical companies and AIDS organizations.

Nowhere is the problem worse than in Arizona, where at least some of the problem stems from stingy politicians. "Arizona ranks 49th in the country for AIDS funding and 27th for infection," says Houle. "It seems with an excess of millions in the state budget that it's time for Arizona's governor and legislature to step up to the plate." In order to ensure the program stays afloat a few more months, Arizona AIDS organizations have anted up $270,000. "We're stealing from Peter to pay Paul," says Houle.

Because ADAP programs are regulated by states, ADAP is a patchwork--indeed, some say a crazy quilt--of regulations and benefits. "Some states cover a very limited number of drugs," says Derek Link of Gay Man's Health Crisis, an AIDS service group. "Some states have caps or various restrictions."

With the introduction of new federal guidelines for HIV treatment advocating early use of protease inhibitors, the strain on ADAP will only increase. Disappointing many activists, the Clinton administration did not request more money for the program in its proposed fiscal 1998 budget. Yet the program should be getting a much-needed injection next year. Currently ADAP receives $167 million. In drafting its budget proposal for 1998, a House of Representatives subcommittee included a $132-million increase. The Senate version of the budget includes a more-modest $50-million increase. Lobbyists hope they can get the larger sum when budget details are hammered out. An expansion of the federal Medicaid system offers the best hope for ending ADAP's problems, advocates say. In some states as many as 75% of ADAP recipients would qualify for Medicaid if the program were open to asymptomatic HIV-positive people. Last spring Vice President Al Gore announced his support for such an expansion of Medicaid, but Congress has shown little inclination to expand federal entitlement programs. Given that climate, AIDS advocates admit they are facing an uphill battle. "I don't think it will happen this year--which means we need the ADAP money," says Link.