HIV/AIDS

Ryan White HIV/AIDS Overview

Authorizing Legislation - Title XXVI of the Public Health Service Act.

*The amounts include funding for Special Projects of National Significance funded from Department PHS Act evaluation set-asides in FY 2007 and proposed for FY 2008.

Statement of the Budget Request - The FY 2008 Budget of $2,157,912,000 is an increase of $95,199,000 above the FY 2007 Continuing Resolution (CR), and supports HIV/AIDS through the Ryan White Care Act as amended.

Program Description - The Ryan White CARE Act was reauthorized in December 2006. The Ryan White CARE Act, as amended, prioritizes lifesaving services for individuals living with HIV/AIDS, including HIV/AIDS medications and primary care; provides more flexibility to target resources to areas that have the greatest needs; encourages the participation of any provider, including faith-based and other community organizations that show results; recognizes the need for State and local planning; and ensures accountability by measuring progress. The request will support a comprehensive approach to address the health needs of persons living with HIV/AIDS, consistent with the reauthorization priorities. These Ryan White CARE Act, as amended, programs administered by the Health Resources and Services Administration's (HRSA) HIV/AIDS Bureau (HAB) provide the focal point for the Federal response to the primary care and social support needs for persons living with HIV disease in the United States.

The Ryan White CARE Act was first enacted in August 1990. It was amended and reauthorized for five years in May 1996, for an additional five years in October 2000 and reauthorized again in December 2006 for three years. Much has changed in the epidemiology and medical management of HIV/AIDS since the Ryan White CARE Act was enacted in 1990. While it used to be that those diagnosed with the disease had little hope, patients today are living longer and healthier lives.

The Centers for Disease Control and Prevention (CDC) now estimates that 1,039,000 - 1,185,000 individuals are living with HIV in the U.S., and approximately 25 percent are not aware of their HIV status. Approximately 40,000 new HIV infections occur in the U.S. every year.

It is estimated that 531,000 unduplicated persons received at least one medical, health, or related support service from a Ryan White CARE Act provider. Specific HIV health services include medical care, access to life saving medications used in the treatment of HIV/AIDS, dental care, outpatient mental health, outpatient substance abuse treatment, and home health care. Key health-related support services include case management, transportation, food bank, and housing assistance. While ambulatory health care and support services are the primary focus of the legislation, training, technical assistance, and demonstration projects are also funded. After Medicaid and Medicare, the Ryan White CARE Act , as amended is the largest single source of Federal funding for health care for low-income, uninsured, and underinsured Americans living with HIV/AIDS.

The Ryan CARE Act programs demonstrate a comprehensive and aggressive approach in how government has targeted dollars toward the development of an effective service delivery system by partnering with States, heavily impacted metropolitan areas, community-based providers, and academic institutions. The Ryan White CARE Act, as amended mandates participatory planning to help insure that the these programs meet the needs of persons living with HIV/AIDS.

Under current statute, Ryan White CARE Act as amended programs (Title XXVI, Parts A-F) include:

1. Part A (Title I) Emergency Relief For Areas with Substantial Need for Services
2. Part B (Title II) HIV Care Grants
3. Part C (Title III) Early Intervention Services
4. Part D (Title IV) Women Infants, Children and Youth
5. Part F: Special Projects of National Significance*
6. Part F: AIDS Education and Training Centers
7. Part F: Dental Schools and Community Based (dental) Care
*[Under statute normally funded by set-asides (not to exceed $25,000,000) from amounts appropriated for Parts A, B, C, and D. For FY 2006 and FY 2007 and proposed for FY 2008, SPNS has or will be funded from Department PHS Act evaluation set-asides.]

The Emergency Relief For Areas with Substantial Need for Services, or Title I (Part A) of the Ryan White CARE Act as amended, provides ambulatory outpatient health and support services to eligible metropolitan areas (EMAs) and transitional areas that are most severely impacted by the HIV epidemic. HIV Care Grants to States, Title II (Part B), provides formula grants to 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and 5 U.S. Pacific Territories and Associated Jurisdictions (American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau) for the provision of health care and support services for people living with HIV disease. A separate appropriation provides critical funding specifically for HIV/AIDS therapies through the AIDS Drug Assistance Program (ADAP), bringing the benefits of effective and costly anti-retroviral and other pharmaceuticals within reach of persons living with HIV who are unable to otherwise afford these therapies.

The Early Intervention Services or Title III (Part C) program funds existing care systems to provide comprehensive primary health care for individuals living with HIV disease who are low-income, medically underserved people. Capacity building grants support health care entities in their efforts to develop high quality HIV primary care for individuals living with HIV disease. Title IV (Part D) programs fund primary care, specialty medical care, psychosocial services, as well as, outreach, prevention and social services for women, infants, children, youth, and auxiliary services for their affected family members. Part F funds the National network of 11 regional AIDS Education and Training Centers (AETC) and several National resource centers that conduct clinical HIV education and training programs for health care providers. Part F also includes the Dental Reimbursement Program that assists accredited dental schools, post-doctorate dental programs and schools of dental hygiene with non-reimbursed costs incurred in providing oral health treatment to patients with HIV disease. Through the Community Dental Partnership Program, dental schools and programs partner with community-based dentists to provide oral health care to patients with HIV disease in underserved areas.

Funding levels for Ryan White HIV/AIDS during the last five years reflect this effort and are as follows:

Performance Analysis - Each year, the Ryan White CARE Act funded programs help an estimated 531,000 individuals living with HIV/AIDS obtain access to life-sustaining care and services. The CARE Act is especially successful in reaching those who need help the most, including minorities, the uninsured and underinsured.

The performance of CARE Act programs is summarized for each component of the program in the sections immediately following the Justification. These summaries generally show success, often exceeding the targets, in extending access to HIV/AIDS services for people living with HIV disease, addressing disparities by serving proportionately large numbers of racial/ethnic minorities and women, providing life-enhancing medications to tens of thousands of persons each month, providing continuing education and training to health providers who treat HIV/AIDS patients, and facilitating affordable dental care needed by persons with HIV/AIDS. (See “Details of Performance Analysis.”)

A Program Assessment Rating Tool (PART) review of the CARE Act programs was conducted for the FY 2004 budget period. These CARE Act programs, combined, received a rating of Adequate. PART has improved program performance and informed the budget-making process. During this process several short-term performance measures were developed to use in assessing performance of the program overall. They include measures to improve access to health care, improve health outcomes, improve quality of health care, and reductions in health disparities. The new measures complement and, in some cases, replaced component-specific measures in performance budget planning and reporting. There are several activities underway as a result of the PART assessment, which include identifying problems and taking corrective action to ensure grantees use funds appropriately through improved grantee monitoring, additional resources, and enhanced compliance activities.

Overall:

• In CY 2004, an estimated 531,000 persons received CARE Act services. In comparison with the annual performance figures from FY 2000, an additional 38,000 clients received services through the CARE Act in FY 2004.
• The CARE Act funded programs are serving a significantly higher proportion of women than the target specified in the indicator itself (i.e., five percentage points higher than the representation of women among all AIDS cases in the Nation, as reported by CDC). The percentage of women served by CARE Act programs was 33 percent in 2005 compared to National CDC AIDS Prevalence data of 24 percent.
• In FY 2005, 572,397 persons learned their serostatus from Ryan White CARE Act programs. In comparison with monthly figures from FY 2004, an additional 18,828 persons or 3.4% additional persons learned their serostatus from CARE Act programs.

Ryan White CARE Act, Part A (Title I) Emergency Relief Grants

Authorizing Legislation- Sections 2601-2607 of the Public Health Service Act as amended.

*The amounts include the proportionate share of funding for Special Projects of National Significance funded from Department PHS Act evaluation set-asides in FY 2007 and proposed for FY 2008.

FY 2008 Authorization.......................................................................................................$626,3000,000.

Statement of the Budget Request - The FY 2008 Budget of $603,993,000 is equal to the
FY 2007 CR, and entirely supports authorized program activities providing for the continuation of services in Eligible Metropolitan Areas (EMAs) and transitional areas..

Program Description - Under current authority, the Ryan White CARE Act as amended, Title I (Part A) program prioritizes primary medical care, provision of anti-retroviral therapies, and medical case management as the areas of greatest need for persons with HIV disease. Title I funds may be used to provide a continuum of care for persons living with HIV disease. The grants fund systems of community-based care to provide 13 core services and other additional social support services for individuals with HIV/AIDS in EMAs and transitional areas. These services are intended primarily for low income, underserved people living with HIV/AIDS. Two-thirds of the funds available are awarded according to a formula based on the number of living cases of HIV/AIDS in the EMAs and transitional areas. The statute also includes a hold harmless provision which limits a potential loss in an EMA’s formula award to a specific percentage of the amount of the awarded in the previous year. The remaining funds, less any hold harmless amounts, are awarded as discretionary supplemental grants based on the demonstration of additional need by the EMA and transitional area and as competitive minority AIDS Initiative grants.

Rationale for the Budget Request - The FY 2008 Request of $603,993,000 is equal to the
FY 2007 estimate. It will provide the following:

• Access to a full spectrum of outpatient medical care to people with HIV disease who do not currently have access to treatment.
  
• Viral load testing for Title I primary care patients.
  
• Title I participation in pharmaceutical assistance and related primary care services for patients receiving combination antiretroviral therapy.
  
• Efforts to improve health outcome disparities of people of color living within the Title I EMAs and transitional areas. (African American, Latinos, American Indians, Alaska Natives, Asian Americans, Native Hawaiians and Pacific Islanders).
  
• Efforts to sustain the capacity of minority service organizations who reach hard-to-serve populations that are disproportionately represented among those infected with HIV.

Funding levels for Part A (Title I) during the last five years reflect this effort and are as follows:

*Excludes comparable amounts for SPNS

Outputs:

Performance Analysis - Title I programs have been successful in providing resources to ensure that people with HIV/AIDS receive the comprehensive care that they need in communities struggling to meet the demands for services locally. Title I grants provide essential HIV/AIDS health care and a wide range of support services to those who lack or are only partially covered by health insurance. These grants help our most affected cities provide the high-quality HIV/AIDS care their residents desperately need, without diverting resources from other areas of the budget. Each year, local communities disproportionately affected by the epidemic rely on the Title I grants to continue delivering quality HIV/AIDS care and improving the lives of their citizens. The CARE Act, with this budget, will continue our commitment to fighting HIV/AIDS through providing access to care and treatment for those most in need.

The Title I program has proven successful based on the program’s performance measures. The number of visits provided for health-related services demonstrates the effectiveness of the Title I program in delivering primary care and related services for individuals infected with HIV/AIDS by expanding the capacity of and access to care. In FY 2005, 3.18 million visits were reported by the 51 Title I EMA grantees. This number exceeded the target of 2.91 million visits. In FY 2005, the program provided PAP smears for 38 percent of women served. The program provided 54 percent of clients with TB skin testing. (See “Details of Performance Analysis.”)

Ryan White CARE Act, Part B (Title II) HIV Care

Authorizing Legislation- Sections 2611-2620 of the Public Health Service Act.

Statement of the Budget Request - The FY 2008 Budget of $1,215,518,000 is an increase of $95,000,000 above the FY 2007 CR. The request supports program activities including increases in medical treatment, life-saving medications, and increased access to care in the hardest hit States.

Program Description - Under current authority, the HIV Care Grants to States, or Title II
(Part B) of the Ryan White CARE Act, as amended provide formula grants to all 50 States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and six eligible U.S. Pacific Territories and Associated Jurisdictions for the provision of core services and social support services for individuals with HIV including: the provision of outpatient and ambulatory health services, oral health care, home and community-based care, support for State AIDS Drug (Pharmaceutical) Assistance Programs (ADAP), Health Insurance Continuation Programs (HICP) for low-income persons with HIV disease and for State direct services.

A State must use a statutorily mandated minimum of its grant funds to provide health and support services to infants, children and women with HIV disease. The statute also contains requirements regarding State matching funds and the use of CARE Act funds to supplement but not supplant State resources. Since 1996, a portion of the appropriation for Title II has been "earmarked" to provide grant funds to States to support their ADAP activities. Title II also provides for supplemental awards to States for Emerging Communities (ECs). The Ryan White CARE Act, as amended now defines emerging communities as metropolitan areas with between 500 and 999 reported AIDS cases over the most recent five-year period. Twenty-seven communities received these supplemental awards in FY 2006 and an estimated nineteen are eligible in FY 2007. The number of ECs for FY 2008 is unavailable at this time.

This year’s Budget also includes funding for a new effort within Title II to target HIV care and treatment funds to those areas of greatest need. These resources will be used to address the unmet need for HIV/AIDS care and treatment, and care for individuals newly diagnosed as a result of increased testing.

Rationale for the Budget Request -The FY 2008 Budget of $1,215,518,000 is an increase of $95,000,000 above the FY 2007 CR. Of this amount $400,972,000 will be used for base formula HIV grants for the provision of services in the fifty States, the District of Columbia, Puerto Rico, the Virgin Islands and six Pacific jurisdictions. This request reflects an increase of $70 million for base formula awards to States over what was requested in the FY 2007 Budget. The additional $70 million will be used to provide health care and treatment services to individuals in greatest need. This request also includes $814,546,000 for State ADAP, an increase of $25 million over what was requested in the FY 2007 Budget. This increase will pay for additional medications in States with limited ADAP formularies, and for the increased cost of HIV/AIDS related pharmaceuticals including anti-retrovirals.

Funding levels for Part B (Title II) during the last five years reflect this effort and are as follows:

*Excludes comparable amounts for SPNS

Outputs - There are 59 grantees funded by this activity including the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands and six Pacific jurisdictions. Fifty-seven of these entities received AIDS Drug Assistance Program funding in FY 2005. In addition, Title II grant awards included funding for twenty-seven Emerging Communities in FY 2006. Nineteen will be eligible in FY 2007. Data needed to determine the number of eligible ECs for FY 2008 will not be available until Fall of CY 2007.

Performance Analysis - The devastating toll of AIDS in America continues to grow. More than 550,394 people have died since 1981, between 1,039,000 and 1,185,000 people are living with HIV/AIDS in the United States today. Approximately 25 percent of those individuals are not aware of their HIV status. The Title II programs have been successful in helping to ensure that people with AIDS can get the care and services they need to stay healthy longer. Poverty, unfortunately, is also associated closely with HIV/AIDS care. When insurance runs out, when savings are depleted, or when disability checks are needed to buy groceries instead of prescriptions, patients can turn to the programs funded by the Title II grants to get life-sustaining medical treatment.

The Title II program has also been successful based on the program’s performance measures as shown in “Details of Performance Analysis”. The number of visits for health-related services demonstrates the effectiveness of the Title II program in delivering primary care and related services for individuals infected with HIV/AIDS by increasing the availability and accessibility of care. In FY 2005, Title II programs provided 2.34 million visits. The actual performance for FY 2005 exceeded the target for that year by 780,000 visits.

Additionally, the number of ADAP clients served through State ADAPs during at least one quarter of the year provides positive evidence of the ADAPs’ ability to provide therapeutics to treat HIV disease or prevent the serious deterioration of health arising from HIV disease in eligible individuals. In FY 2005, 131,808 clients were served through State ADAPs during at least one quarter of the year. The way we collect this data has changed. The actual FY 2005 performance cannot be compared with the FY 2005 target because the actual performance is based on the revised measure using quarterly data and the target is based on the former measure utilizing monthly program data. This same rationale applies to the comparison of actual performance from FY 2004, which is based on monthly client counts and FY 2005, which is based on quarterly client counts. The actual FY 2005 program results and the 2006-2008 targets are based on the data submitted on the ADAP Quarterly Report. Actual performance for 2002-2004 and the 2005 targets are based on the ADAP Monthly Report (AMR).

Ryan White CARE Act, Part C (Title III) Early Intervention Services

Authorizing Legislation- Sections 2651-2654 of the Public Health Service Act.

*The amounts include the proportionate share of funding for Special Projects of National Significance funded from Department PHS Act evaluation set-asides in FY 2007 and proposed for FY 2008.

FY 2008 Authorization....................................................................................................$226,700,000

Statement of the Budget Request - The FY 2008 Budget of $199,821,000 is an increase of $6,199,000 above FY 2007 CR. The request includes $6,199,000 to continue grants to community based health care organizations to provide early intervention services including primary care and support services for people living with HIV/AIDS.

Program Description - The Ryan White CARE Act, as amended Title III (Part C) program has increased access to health care for low income and medically underserved individuals who are infected with HIV or who are at risk for HIV infection by providing early intervention service programs. Title III funds are awarded to family planning agencies, comprehensive hemophilia diagnostic and treatment centers, federally qualified health centers under section 1905(1)(2)(B) of the Social Security Act, rural health clinics, Indian Health Service clinics and other nonprofit community-based programs that provide comprehensive primary health care services to populations with or at risk for HIV disease. Currently, 363 Early Intervention Services (EIS) programs provide comprehensive, primary care services to approximately 212,471 people living with HIV/AIDS in 49 States, the District of Columbia, Puerto Rico, and the Virgin Islands.

The programs emphasize core services and early intervention services aimed at preventing and/or reducing HIV-related morbidity as part of the program of comprehensive primary care. Early intervention consists of the medical, educational, and psychosocial services designed to prevent the further spread of HIV, forestall the onset of illness, facilitate access to services, and provide psychosocial support to HIV-infected individuals and their families.

Part C (Title III) programs provide health care for individuals who are infected with HIV. The programs provide comprehensive services including HIV testing, risk reduction counseling, partner involvement in risk reduction, transmission prevention appropriate medical evaluation, oral health, nutritional and mental health services, and clinical care (such as CD4 cell monitoring, anti-retrovirals therapy, prophylaxis, and treatment of opportunistic infections and other related conditions). Case management, outreach, and eligibility assistance are optional services under this program. Programs are required to deliver primary care services to those with HIV disease and take into account the changing demographics of HIV-infected populations. Programs are also required to demonstrate that the provision of care follows current accepted treatment protocol.

Part C (Title III) also provides for two types of planning grant awards to organizations that may not otherwise receive CARE Act funds. These planning grants are designed to help communities plan for the provision of high quality comprehensive HIV primary health care services in rural or urban underserved areas and communities of color where no or limited HIV services exist. They may not exceed $50,000 and are for only one fiscal year. Additionally, grants are awarded to provide capacity building for organizations efforts to strengthen their organizational infrastructure and enhance their capacity to develop, enhance or expand high quality HIV primary health care services in rural or urban underserved areas and communities of color. These grants may not exceed $150,000 over a three year-period.

Rationale for the Budget Request - The FY 2008 Budget of $199,821,000 is an increase of $6,199,000 above the FY 2007 CR. At this level, the program will continue to fund existing Title III (EIS) Programs and will sustain primary health care and social support services to people living with HIV and AIDS at 363 EIS grantee sites in 48 States, D.C., Puerto Rico and the U.S. Virgin Islands. The additional $6,199,000 request will be used to provide increases to the currently funded EIS programs who have documented, increased costs of care and unmet need for early intervention services in the community.

Performance Analysis - The Title III program has been successful in providing critical support to the organizations caring for, or planning to care for, some of the most vulnerable populations infected by HIV/AIDS. Early and continuous care can help these individuals live longer, more productive lives. HIV/AIDS continues to grow among traditionally underserved and vulnerable groups and people of color. Women, racial/ethnic minorities and youth, in particular, remain disproportionately affected by the epidemic. The Title III program provides essential services that many of these people cannot get anywhere else because they are either unable to pay or do not qualify for the services, or because the services themselves are not otherwise available.

The Title III program has proven successful based on the program’s primary performance measure outlined in “Details of Performance Analysis”. The number of individuals receiving primary care services through the Early Intervention Services (EIS) Program demonstrates the effectiveness of the Title III program in achieving increased access to care for individuals infected with HIV/AIDS. In FY 2004, the Title III (EIS) Program served 212,471 clients, exceeding the targeted goal by 34 percent, and representing an increase of 11.1 percent in new clients served compared to FY 2003.

 Ryan White CARE Act, Part D (Title IV) Children, Youth, Women, and Families

Authorizing Legislation -  Section 2671 of the Public Health Service Act.

*The amounts include the proportionate share of funding for Special Projects of National Significance funded from Department PHS Act evaluation set-asides in FY 2007 and proposed for FY 2008.

FY 2007 Authorization.......................................................................................................71,800,000.

Statement of the Budget Request - The FY 2007 Request of $71,794,000 is equal to the

FY 2006 appropriation.

Program Description - The purpose of the Part D (Title IV) Ryan White CARE Act as amended, under current authority, is to improve and expand primary care and support services in order to increase access to comprehensive, family-centered systems of care. HIV-infected children, youth and women and affected family members have multiple, complex medical, economic and social service needs which often require more intensive care coordination, intensive case management, child and respite care, and direct service delivery to engage and maintain adolescents and mothers in care.

A special focus of the Title IV program is to help identify HIV-positive pregnant women, connect them with care that can improve their health, and prevent perinatal transmission. Assessment and provision of services is delivered at the family level, and usually involves services not only for the infected child(ren) and parent(s), but also support services for uninfected siblings and care givers. Services to families may involve coordination of multiple agencies and systems, including managed care organizations, faith-based organizations, social services and foster care agencies.

Rationale for the Budget Request - The FY 2008 Budget of $71,794,000 is equal to the
FY 2007 CR. The request will sustain primary health care and social support services to over 53,000 women, infants, children and youth living with HIV and AIDS and their affected families at grantees situated in 31 States, D.C. and Puerto Rico.

Funding levels for Part D (Title IV) during the last five years reflect this effort and are as follows:

Performance Analysis - The HIV epidemic in America impacts the most vulnerable families more and more each year. The Title IV program has been successful in providing front-line services to many women and children, filling a critical need in the delivery of health care services to persons living with HIV/AIDS. Because women frequently neglect their own health to care for their families, making sure they have access to quality HIV/AIDS care and services is critical. Before women can adequately care for their families, they must care for themselves, and the Title IV programs have shown success in helping bridge this gap.

The Title IV program has proven successful based on the program’s performance measures as shown in “Details of Performance Analysis.” The number of female clients receiving comprehensive services demonstrated the effectiveness of the Title IV program by providing HIV-infected children, adolescents, women and families increased access to care. In FY 2005, 52,306 females were served in the Title IV program which exceeded the performance target by nearly 60 percent and this represented a 7.2% increase over FY 04.

Ryan White CARE Act, Part F:  AIDS Education and Training Centers

Authorizing Legislation -  Section 2692 (a) of the Public Health Service Act.

FY 2008 Authorization.................................................................................................$34,700,000

Statement of the Budget Request - The FY 2008 Budget of $28,700,000 is a decrease of $6,000,000 below the FY 2007 CR.

Program Description - The National AIDS Education and Training Centers (AETC) Program is a network of 11 regional centers (with more than 130 associated sites) that conduct targeted, multi-disciplinary HIV education and training for health care providers. The AETCs serve all 50 States, the District of Columbia, the Virgin Islands, Puerto Rico, and the six U.S. Pacific Jurisdictions. The AETC Program mission is to increases the number of health care providers who are effectively educated and motivated to counsel, diagnose, treat, and medically manage individuals with HIV infection, and to help prevent