HIV/AIDS PROGRAMS

Programs included in this section are:

• HIV/AIDS: Ryan White HIV/AIDS Program
• HIV Emergency Relief Grants (Part A)
• HIV Care Grants to States (Part B)
• HIV Early Intervention Services (Part C)
• HIV Children, Youth, Women, and Their Families Grants (Part D)
• AIDS Education and Training Centers (Part F)
• Dental Reimbursement and Community Partnership Programs (Part F)
  

Ryan White HIV/AIDS Treatment Modernization Act of 2006

Notes:

^a DNA = Data not available.  Due to the aggregate nature of the CADR data and the way the race/ethnicity questions are currently phrased, the proportion of racial/ethnic minorities served by the Ryan White HIV/AIDS Program can not be calculated for 2002-2004.

^b CDC’s data for comparison is not available as of this writing.

^c The FY 06 target is based on number of persons served at least one quarter of the year, rather than number of persons served    annually.  The FY 07 and FY 08 targets differ from those shown in the FY 08 Congressional Justification to reflect actual funding levels.

^d The FY 07 and FY 08 targets differ from those shown in the FY 08 Congressional Justification because targets were reset in the                    FY 07 PART reassessment.

^e This target was established during the PART reassessment, and therefore differs from previously reported targets.

^f  Cost-saving strategies are defined as rebates, third party reimbursements, and direct negotiations with pharmaceutical companies.

* During the FY 07 PART reassessment of the Ryan White HIV/AIDS Program, minor changes were made in the wording of some measures.

INTRODUCTION

The Ryan White HIV/AIDS Program’s performance measures are tied to HRSA’s overall goals, which serve as the performance management framework for the Program. The measures allow the Program to track progress toward reaching these goals.  Specific performance measures are linked to the following HRSA goals: Improve Access to Health Care by expanding the capacity of the health care safety net; Improve Health Outcomes by expanding the availability of health care, particularly to underserved, vulnerable, and special needs populations; Improve the Quality of Health Care; and Improve the Public Health and Health Care Systems.   

Several cross-cutting long-term and annual measures have been identified to use in assessing the Ryan White HIV/AIDS Program’s performance.  Because these goals are related to the program as a whole, rather than to specific Parts, they are presented in aggregate below.  This is followed by additional Part-specific measures.

Performance measure information is used by the program to identify potential policy issues, to share best practices, for providing accountability for results, to assess training needs of Project Officers in order to assure better monitoring of grantee performance, and to evaluate the effectiveness of the program and activities and the resources spent on conducting them.

The Ryan White HIV/AIDS Program uses various strategies to achieve the performance goals including targeting resources to address the unmet care and treatment needs of persons living with HIV/AIDS who are uninsured or underinsured and therefore unable to pay for HIV/AIDS health care and vital health-related support services; assuring patient adherence and compliance (e.g., through patient education and follow-up); directing outreach and prevention education and testing to populations at disproportionate risk for HIV infection; tailoring health care and related services to populations known to have delayed care seeking behaviors (e.g. varying hours, care offered in various sites, linguistically and culturally appropriate service provision); and assuring that appropriate services are being provided in areas of greatest need, including where there are high rates of HIV infection, rural areas, and in communities with health disparities.  In many instances, the Program collaborates with other Federal, State and local providers who conduct HIV testing to encourage them to refer clients who test positive to Ryan White HIV/AIDS Programs for treatment.   

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective:  Expand the Capacity of the Health Care Safety Net

16.1. Number of racial/ethnic minorities and the number of women served by Ryan White HIV/AIDS-funded programs.

(Baselines - 2005: 412,000/195,000; Targets - 2014: 422,300/199,875)

16.I.A.1. Proportion of racial/ethnic minorities in Ryan White HIV/AIDS-funded programs served.  (exceeding their representation in national AIDS prevalence data reported by the CDC)

Despite the reduction seen in overall AIDS mortality, annual incidence data show that the proportion of AIDS cases among racial/ethnic minorities continues to increase. In addition, benefits provided by new combination drugs (anti-retrovirals/protease inhibitors/HAART) have not uniformly reduced the disparities in incidence of AIDS among racial/ethnic minorities.  The proportion of racial/ethnic minorities served by the Ryan White HIV/AIDS Program was selected as a measure demonstrating progress toward the program’s goal to improve access to health care among individuals infected with HIV/AIDS by increasing utilization for traditionally underserved populations.

Ryan White HIV/AIDS-funded programs serve a significantly higher proportion of racial/ethnic minorities than the target, which is five percentage points higher than the representation of racial/ethnic minorities among all AIDS cases in the Nation, as reported by CDC.  The proportion of Ryan White clients who were racial/ethnic minorities in 2005 was 72%, compared to the 64.1% of CDC-reported AIDS cases.  Seventy-two percent (72%) of clients served in Ryan White HIV/AIDS-funded programs in FY 06 were racial/ethnic minorities. (The CDC AIDS data for comparison is not available as of this writing.)  The FY 09 target for the proportion of racial/ethnic minorities served by the Ryan White HIV/AIDS Program continues to be 5 percentage points above CDC data for the same period.

16.I.A.2. Proportion of women in Ryan White HIV/AIDS funded-programs served.

(exceeding their representation in national AIDS prevalence data reported by the CDC)

Despite the reduction seen in overall AIDS mortality, annual incidence data show the proportion of AIDS cases among women continues to increase.  In addition, benefits provided by combination drugs (anti-retrovirals/protease inhibitors/HAART) have not uniformly reduced the disparities in incidence of AIDS among women.  The proportion of women served by the Ryan White HIV/AIDS Program was selected as measure demonstrating progress toward the program’s goal to improve access to health care among individuals infected with HIV/AIDS by increasing utilization for traditionally underserved populations.

The Ryan White HIV/AIDS-funded programs are serving a significantly higher proportion of women than the target, which is five percentage points higher than the representation of women among all AIDS cases in the Nation, as reported by CDC.  In 2005, 33% of persons served by the Ryan White HIV/AIDS Program were women, compared to 24% of CDC-reported AIDS cases.  The proportion of women served by the Ryan White HIV/AIDS Program in 2006 was 33%.  (The CDC AIDS data for comparison is not available as of this writing.)  The FY 09 target for the proportion of women served by the Ryan White HIV/AIDS Program is 5 percentage points above CDC data for the same period.

Long-Term Objective:  Expand the Availability of Health Care, Particularly to Underserved, Vulnerable, and Special Needs Populations

16.2. Deaths due to HIV infection below 3.1 per 100,000 people.

(Baseline - 2003: 4.7 per 100,000; Target - 2014 3.1 per 100,000)

16.II.A.1. Number of AIDS Drug Assistance Program (ADAP) clients served through State ADAPs annually.

The number of ADAP clients served through State ADAPs annually was selected as a measure demonstrating progress toward the program’s goal to improve health outcomes among individuals with HIV/AIDS who are underserved by increasing availability and utilization of essential medications.  Many clients are enrolled in ADAP only temporarily while they await acceptance into other insurance programs, like Medicaid.

In 2006, the AIDS Drug Assistance Program (ADAP) served 157,988 clients through State ADAPs.  This can not be compared with the FY 06 target because the actual performance is based on a revised measure using annual data and the target is based on a previous measure based on quarterly utilization.  The number of ADAP clients served through State ADAPs annually in 2006 was 10,801 persons above the 2005 results.  The FY 09 target for clients served through State ADAPs is 158,887.  The Program’s marginal cost model corroborates the projected target for number of ADAP clients served in 2009.  (See section below on “Targets Substantially Exceeded or Not Met.”)

16.II.A.2. Number of persons who learn their serostatus from Ryan White HIV/AIDS Programs.

The number of individuals who learn their serostatus from the Ryan White HIV/AIDS Programs was selected as a measure demonstrating progress toward achieving the program’s goal to improve health outcomes for individuals infected with HIV/AIDS by increasing access to services. Knowing one’s HIV status helps prevent the spread of HIV.  Additionally, early diagnosis and treatment can vastly improve the quality and length of life.

In FY 05, the Ryan White HIV/AIDS Program provided 572,397 persons confirmation of their serostatus, exceeding the target by 7,757.  This represents an increase of 18,828 persons and a 3.4% increase compared to FY 04.  Ryan White HIV/AIDS Program dollars are used for HIV testing only when HIV testing is not otherwise available.  The FY 09 target for persons learning their serostatus from Ryan White HIV/AIDS Programs is 572,397.

16.II.A.3. Percentage of HIV positive pregnant women in Ryan White HIV/AIDS Programs who receive Anti-Retroviral Medications.

The percentage of HIV positive pregnant women in Ryan White HIV/AIDS Programs who received anti retroviral medications was selected as a measure demonstrating progress toward achieving the Program’s goal to improve health outcomes for individuals infected with HIV/AIDS by increasing access to services to reduce perinatal transmission.  Approximately 100,000 childbearing-aged women in the United States are infected with human immunodeficiency virus (HIV), and an estimated 7,000 infants are born to HIV-positive mothers each year. In the United States, the rate of perinatal transmission of HIV among mothers who do not receive antiretroviral therapy is 25%- 30%.  The transmission risk can be reduced to below 8% when pregnant women receive antiretroviral medications.

In FY 05, the Ryan White HIV/AIDS Program provided 85.3% of HIV-positive pregnant women in Ryan White HIV/AIDS Programs with anti-retroviral medications.  This was the baseline number and therefore targets were not set for this year.  The FY 09 target for the percentage of HIV-positive pregnant women in Ryan White HIV/AIDS programs receiving anti-retroviral medication is 89.3%.

Long-Term Objective:  Promote Effectiveness of Health Care Systems

16.3 Ryan White HIV/AIDS Program-funded HIV primary medical care providers will have implemented a quality management program and will meet two “core” standards included in the October 10, 2006 “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.”

(Baseline - 2005: 63.7%; Target - 2014 90%)

16.III.A.1. Percentage of Ryan White HIV/AIDS Program-funded primary medical care providers that will have implemented a quality management program.

A major goal of the Ryan White HIV/AIDS Program is to improve the quality of care that its clients receive. The number of Ryan White HIV/AIDS Program-funded grantees that implement a quality management program was selected as a key performance measure because having a quality management program is essential to continued quality improvement. 

By FY 06 88.6% of medical care providers had implemented a quality management program.  This exceeded the target by 18.6 percentage points.  Additionally, the FY 06 results represent a growth by 2.9 percentage points over the FY 05 data which indicated that 85.7% of primary care providers had implemented a quality management program.  The FY 09 target for the measure is 95.7%.

16.III.A.2. Proportion of new Ryan White HIV/AIDS Program HIV-infected clients who are tested for CD4 count and viral load.

The proportion of new Ryan White HIV/AIDS Program HIV-infected clients that are tested for CD4 count and viral load was selected as a good measure demonstrating progress toward the program goals to improve quality of health care for individuals infected with HIV/AIDS.

In 2006, the Ryan White HIV/AIDS Program provided CD4 count testing to 84.9% of new clients and Viral Load testing to 82.5% of these new clients.  This exceeded the target for CD4 tests by 4.9 percentage points and exceeded the target of new clients receiving Viral Load testing by 7.5 percentage points.  This performance has improved over the FY 05 baseline of 83.2% of new clients receiving CD4 counts and 79.3% of new clients receiving viral load testing.  The FY 09 target for CD4 is 87.2% and Viral Load is 83.3%.

16.E. Amount of savings by State ADAPs participation in cost-savings strategies on medications.

Cost-containment strategies are important as more clients are seeking treatment with dramatic increases in the cost of new treatments, and rapidly changing standards of care. This challenges ADAPs to contain costs at the same time they are asked to expand access.  As a result, ADAPs have taken a number of steps to stretch dollars. These include changing the system used to purchase/distribute drugs, seeking larger price discounts or rebates on drugs (e.g., through participation in the Section 340B Drug Discount Program), third party reimbursement, and direct negotiations with pharmaceutical companies.

ADAP’s savings strategies on medications resulted in a savings of $76 million in 2002, $92.5 million in 2003, and $143.5 million is 2004.  In 2005 the ADAP program had cost-savings on medications of $275 million, exceeding the target by $128.7 million.  The FY 09 target for ADAP cost savings is 1 percent over the FY 08 results.

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure:  Number of AIDS Drug Assistance Program (ADAP) clients served through State ADAPs annually.

FY 06 Target: 131,808 clients

FY 06 Result: 157,988 clients

A major reason that the target was exceeded is that Medicare Part D, which covers the cost of prescription drugs for eligible persons, was implemented in 2006. ADAP clients who are eligible for Medicare Part D had some of their prescription drug costs covered by Medicare.  Another reason is State ADAPs’ purchase of private health insurance for clients to cover the cost of HIV/AIDS medications.  Both of these initiatives yield “savings” that permit more persons to be served by ADAP programs.  It should also be noted that the target is related to clients served at least one quarter of the year, whereas the result is clients served annually. 

The Ryan White HIV/AIDS Program has adjusted future ADAP targets to reflect the performance in FY 06.  The Program continues to promote use of cost-saving strategies by ADAP grantees. 

The impact of this result is that more people, primarily low-income persons who have limited or no access to needed medications, had access to essential medications to treat their disease and/or prevent the serious deterioration in health arising from their HIV disease.

HIV Emergency Relief Grants (Part A)

Notes:

^a This FY 08 target was changed from that shown in the FY 08 Congressional Justification to be consistent with recent performance.

DISCUSSION OF RESULTS AND TARGETS

Long – Term Objective: Promote Effectiveness of Health Care Services

17.III.A.1. Proportion of women that receive PAP screening. 

Cervical Intraepithelial Neoplasia (CIN) refers to cellular changes in the cervix, thought to be precursors of cervical cancer that can be detected with PAP screening. Researchers conclude that HIV+ women are three times as likely as HIV negative women to have CIN.  Women with HIV are more likely to develop cervical cancer than other women.  The possibility increases to 30 times as likely if a woman has HIV and HPV, the human papilloma virus. 

In FY 06, the Part A program provided 40.8% of women served with PAP screening.  This fell short of the target of 47.4 by 6.6 percentage points.  The proportion of women receiving PAP screening had increased from 35.8% in 2004 to 38% in 2005 and the 2006 result shows another increase.  The FY 09 target is baseline plus 1.5% or 47.4% of women receiving PAP screening.  (See section below on “Targets Substantially Exceeded or Not Met.”)

17.III.A.2. Increase the proportion of clients that receive TB skin tests. 

Latent TB is much more likely to become active TB in someone with HIV.  TB is an AIDS-defining condition.  The CDC recommends HIV-infected persons get tested for TB, with a TB Skin Test (TST).  There are a number of instances where annual TB testing for HIV-infected individuals is not supported.  For instance, 10-15% of HIV-infected individuals who already have TB are not receiving annual TB skin tests.  Additionally, persons who have documented false positive TB skin test results and those that have a current skin rash that interferes with reading the test results are not given annual TB skin tests. 

In FY 06, the Part A program provided 52.5% of clients with TB skin tests.  This fell short of the target by 3 percentage points.  There has been a rise in the proportion of clients receiving TB skin testing from 28% in FY 04 and 54% in FY 05.  Patient outreach and follow-up are among the strategies grantees use to achieve targets.  The FY 09 target is to sustain FY 08 results. 

Long – Term Objective:  Expand the Capacity of the Health Care Safety Net

17.I.A1. Number of visits for health-related care (primary medical, dental, mental health, substance abuse, rehabilitative, and home health) to a level that approximates inclusion of new clients.

The number of visits provided for health-related services was selected as a measure demonstrating progress toward the program goal to improve access to health care and related services for individuals infected with HIV/AIDS by increasing availability of and access to care.

In FY 06, 2.47 million visits were reported by 56 Part A Eligible Metropolitan Area (EMA) grantees and Transitional Grant Areas (TGAs).  This number fell short of the target by 440,000 and was 710,000 visits less than the previous year.  The FY 09 target for visits for health-related care is 2.44 million visits.  More than 1,500 providers of funded and eligible services provided health care and related supportive services to hundreds of thousands of persons living with HIV/AIDS. (See section below on “Targets Substantially Exceeded or Not Met.”)

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure:  Proportion of women that receive PAP screening.

FY 06 Target: 47.4%  (Baseline, 45.9% plus 1.5%)

FY 06 Result: 40.8%

The proportion of women that receive PAP screening has continued to increase over time with 35.8% of women receiving PAP screening in FY 04, 38% in FY 05 and 40.8% in FY 06.  The proportion of women receiving PAP screening in FY 06 fell below the target for a variety of reasons including: the PAP screening results are not documented in the patient chart, the PAP results in the chart may not be entered in the data base used to report performance data to the Program, the PAP screenings are done at locations other than HIV Clinics, and the reluctance of patients to have PAP screening.

The Program has initiated a special initiative to improve the PAP screening rates.  The initiative includes providing technical assistance through the National AETC and the National Quality Center to HIV medical providers, providing Project Officers with the tools to understand the PAP screening data that grantees submit, and follow up with grantees regarding identifying barriers and improving reporting.  

While the FY 06 target was not met, the Program has been successful in increasing, each year, the proportion of clients receiving PAP testing.  Cervical cancer can often be prevented or detected in its earliest stages through effective screening with a PAP smear and avoidance of known risk factors.  This accentuates the importance of routine gynecological care, which includes PAP smears for HIV-infected women.  The impact of annual improvements in this result is that HIV-related morbidity is improved and essential information is available to inform treatment decisions.

Measure:  Number of visits for health-related care (primary medical, dental, mental health, substance abuse, rehabilitive, and home health) to a level that approximates inclusion of new clients.

FY 06 Target: 2.91 million visits

FY 06 Result: 2.47 million visits

The number of visits for health-related care (primary medical, dental, mental health, substance abuse, rehabilitative, and home health) to a level that approximates inclusion of new clients has continued to decrease annually and the FY 06 number of visits fell below the target by 440,000 visits.  There has been a declining trend in client visits is the past years as follows.  In FY 04 there were 3.11 million health-related care visits reported and FY 05 produced 3.18 million visits. The decrease in visits may be the result of fewer Part A providers and fewer clients served, and the impact of health care inflation. 

The Ryan White HIV/AIDS Program has adjusted future targets to reflect the performance in FY 06.  Patient outreach and follow-up are among the strategies grantees use to achieve targets.

While the target was not met, the visits provided by the Part A programs indicate that many low-income, uninsured and underinsured people affected by HIV/AIDS had access to care and support services delivered in eligible metropolitan areas and transitional grant areas.

HIV Care Grants to States (PART B)