Kathleen A. McManus, MD, (center) and other co-investigators
Researchers from the University of Virginia’s (UVA) McManus Research Group and the National Alliance of State & Territorial AIDS Directors (NASTAD) presented three posters at the 33rd Conference on Retroviruses and Opportunistic Infections (CROI) in February 2026.
The interdisciplinary team, led by Kathleen A. McManus, MD, in UVA’s Division of Infectious Diseases and International Health, spans multiple UVA schools, including the School of Medicine, School of Nursing, School of Data Science, as well as external institutions. Co-investigators include Erin Q. Rogers, PhD, Reanna Panagides, Jessica Keim Malpass, PhD, RN, Amber Steen, Stephen Turner, Amy Killelea, Tim Horn, at NASTAD, and Elizabeth Rogawski McQuade, PhD, at Emory University. Through partnership with eight state health departments, whose ADAP programs contribute insights and client-level data, this work is grounded in real-world HIV care delivery. The study also includes a qualitative component with sixteen states sharing AIDS Drug Assistance Program (ADAP) best practices.
ADAPs are a cornerstone of the Ryan White HIV/AIDS Program, providing antiretroviral therapy (ART) and insurance assistance to low-income people living with HIV, which is essential for maintaining viral suppression, improving survival, and preventing HIV transmission. Disruptions in ADAP coverage can lead to treatment interruptions, increased viral load, and adverse clinical outcomes, underscoring the importance of stable enrollment.
The first study, “Longitudinal Enrollment and Churn in the AIDS Drug Assistance Program in 3 States, 2014–2021,” evaluated patterns of ADAP “churn” – transitions on and off coverage – among nearly 29,000 clients in Arizona, Maryland and Virginia. Participants were followed for five years on average. Clients spent nearly half (43%) of their time outside of active coverage, limiting consistent access to ART. Churn was more common among younger adults and Black/African American and Hispanic/Latino clients, reflecting persistent inequities in access to care. Enrollment in ADAP-supported insurance programs was associated with a 16% reduction in churn, suggesting that insurance-based delivery models may improve treatment continuity treatment for populations at highest risk of coverage instability.
The second study, “Some Barriers Persist, But State AIDS Drug Assistance Programs’ Challenges Ease Overall: 2017–2023”, used national survey data from ADAP leadership across all 50 states and the District of Columbia to assess trends in programmatic barriers. Barriers that have improved include reduced restrictions on single-tablet regimens, expanded provider networks, and fewer limitations related to enrollment and premium payment processes. However, persistent challenges remain, including high cost-sharing for HIV medications, constraints related to mail-order and specialty pharmacies, and client churn to new plans or programs. These findings suggest that while program-level improvements have been achieved, structural barriers tied to insurance design continue to impact access to HIV treatment.
Kathleen A. McManus, MD, (far right) and other co-investigators
The third study, “Medicaid and State AIDS Drug Assistance Programs: The Impact of the Public Health Emergency,” used NASTAD’s longitudinal monitoring data to examine how COVID-19 pandemic policy shaped ADAP enrollment from 2016 to 2023. Federal continuous coverage requirements during the Public Health Emergency (PHE) reduced reliance on ADAP, with enrollment declining in 34 states. Following the PHE’s end and resumption of Medicaid eligibility redeterminations, ADAP enrollment increased, particularly in Medicaid expansion states. The findings highlight the interdependence of Medicaid and ADAP and demonstrate how Medicaid policy shifts immediately drive ADAP demand. With federal policy changes anticipated to increase Medicaid churn in coming years, ADAPs will need contingency plans to absorb new enrollment pressure.
The McManus Research Group’s collaboration with NASTAD exemplifies interdisciplinary, translational research grounded in partnerships with state health department HIV leaders. By combining NASTAD’s longitudinal monitoring dataset with client-level ADAP data, the team addresses policy-relevant questions that clinical data alone cannot answer. Together, these presentations send a unified message: ADAPs are essential to HIV care delivery, and their effectiveness depends on the broader policy environment.
The UVA team’s contributions at CROI 2026 extended beyond the ADAP-focused studies. Drs. McManus and Rogers co-authored a poster with Emory collaborators titled “Safety-Net Strain Ahead: High Uninsurance Among Patients With Advanced HIV at a Ryan White Clinic.” Dr. McManus also collaborated with Catherine Bielick, MD, on two additional studies: “Regional Disparities in HIV Opportunistic Infections Persist Despite National Declines, 2011–2022” and “Causal Forecasting of Regional Opportunistic Infections With Improved Insurance Coverage Simulations.” Dr. Bielick, a recent UVA Infectious Diseases fellow and School of Data Science graduate, is now a faculty member at Beth Israel Deaconess Medical Center and the recipient of an NIAID K08.
Collectively, these six CROI 2026 presentations reflect the McManus Research Group’s integration of epidemiology, data science, health policy, and implementation science to improve health outcomes for people with HIV in the United States.
For more information, contact Dr. McManus at km8jr@virginia.edu.
This project is supported by the National Institute of Allergy and Infectious Diseases of the NIH under award number R01AI170093. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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