When Cuts Cost More: Projected Fiscal Impact of Eliminating the AIDS Drug Assistance Program in 30 US States.

Background: The 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. Methods: Using 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. Results: Across 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). Conclusions: Eliminating ADAP would be medically and fiscally counterproductive, increasing HIV burden and generating healthcare costs that would exceed program savings within seven years.