• Should priority go to drugs and/or medical care?
• Can we meet these goals without spending more money? 

There is no consensus on the answer to the prioritization question. There are countless
discussions around cost-effectiveness in general.  There are also heated debates on
the most cost-effective use of federal, state, and local funding stream contributions to
reduce the increasing financial strain on emergency room, hospital intensive care, and
home healthcare for people with AIDS who have not had access to appropriate drugs
and care to prevent their HIV disease progression.
 

While the President's chosen approach is laudable for its sense of emergency and
demand for fast action, our government has not been successful in solving the domestic
ADAP crisis by allocating adequate ADAP funds or the international AIDS crisis by
facilitating delivery of the promised HIV drugs to the epicenters of the pandemic. This has
been an embarrassment to many.
 
Our government's approach to HIV drug access can be fraught with problems for people
with HIV disease, ADAP programs, and state and federal administrative staff. Our current
policies are embedded with political and ethical time bombs. The fiscal year 2005 ADAP
financial need was for $217 million in budget appropriations with $117 million made available
now via an ADAP Emergency Supplemental Appropriation.  However, the Administration has
attempted to respond to the waiting list challenge with a $20 million stop-gap plan.  The $20
million will probably solve about 10% of the known ADAP problems - but it will not solve the
central problem of drug access for the several thousands of medically indigent diagnosed
with HIV every year that will turn to an ADAP for a lifeline.

With these problems still unresolved, are we grateful for solving 10% of the problem? Yes,
we are very grateful. Raising the issue in a Presidential speech was a definite act of
political leadership and clearly demonstrates that something must be done quickly. This is
certainly real political leadership on the part of President Bush and Secretary Thompson on
an issue of great importance to Hispanic, African-American, and Gay and Lesbian
communities. Even if the solution proposed is just a “start” to solving the problem we should
be grateful for the Presidents’ actions. Is it our responsibility to continue the work and even
step-up our efforts to solve the remaining 90% of the ADAP crisis?  Of course it is.
.

States that have worked long and hard to secure funds to insure that their ADAP
programs did not have to reduce their drug formularies,  restrict their eligibility
requirements, or implement waiting lists are unhappy about the equity of the White
House initiative. For example, there are several states faced with having to create
waiting lists in the next few weeks and months, and those states are audibly angry.
 
Sometimes in the rush to implement a new policy that may have significant benefits
for some, we may fail to thoroughly evaluate the consequences of the policy on others.
This is the fundamental challenge of distributive or social justice. Many states have
been understandably disturbed over the equity of this policy and are asking:

• "Why did people with HIV disease in state "x" get special attention and our
  people were ignored?" 
• "We run a far better and more comprehensive ADAP program than than does
  state "x" and our people are getting a raw deal."
• "They are going to send drugs to people in a state that doesn't even have
  protease inhibitors on the ADAP formulary. Our formulary covers antiretrovirals
  and OI [opportunistic infection] drugs How fair is that?" 
• "We have to open an ADAP waiting list in eight days. Why won't the
  Administration help us?"

Because there are always life and death implications on drug access policies, one
should expect hard questions on any policy perceived to be inequitable. Many of
these questions come from those  who work with ADAP applicants. Their hearts
often break when they are unable to help those who look to them for access to HIV
drugs. Some secretly dream of performing "loaves-and-fishes"-type miracles and
providing unlimited drugs for all who need them. But dreams are only dreams. The
reality is that they must often settle for less perfect and sometimes painful resolutions.

This welcome gesture from President Bush should not make future appropriations any
more difficult. The needs all remain as they have been for the last 3 to 4 years. Each
month 450 to 650 people with HIV look to ADAPs for access to HIV treatment. We will
either have the political will to ensure that these patients get appropriate treatment for
their disease or we won’t and everything remains as it was. We sometimes forget that
HIV attacks both the person and the society. Unless people with HIV disease get access
to effective drugs, they suffer and die.  And our society also suffers and dies. We suffer from
the financial burden of end-stage HIV care and slowly die from the loss of our moral sense of
right and wrong as we refuse to  to help the most vulnerable among us who depend on us for
their survival.