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Ryan
White HIV/AIDS Overview
Ryan White HIV/AIDS Treatment Modernization
Act of 2006
|
FY
2007
Actual |
FY
2008
Enacted |
FY
2009
Estimate |
FY
2009 +/-
FY 2008 |
BA |
$2,112,795,000
|
$2,141,792,000
|
$2,142,912,000
|
$1,120,000
|
PHS
Act (SPNS) |
25,000,000 |
25,000,000 |
25,000,000 |
--- |
Total |
$2,137,795,000
|
$2,166,792,000
|
$2,167,912,000
|
$1,120,000
|
FTE |
28 |
30 |
30 |
--- |
*The amounts include funding for Special Projects
of National Significance (SPNS) funded from Department
PHS Act evaluation set-asides in FY 2008 and proposed
for FY 2009.
Authorizing Legislation: Title XXVI of the Public
Health Service Act, as amended.
FY 2009 Authorization |
$2,289,300,000 |
Allocation Method |
Competitive and Formula Grants, Cooperative
Agreements and Contracts |
Summary of Request
The purpose of the Ryan White HIV/AIDS Treatment Modernization
Act of 2006 (Ryan White HIV/AIDS Program) is 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 supportive services. Ryan White
HIV/AIDS Program funding pays for core primary health
care and support services that enhance access to and
retention in care and fills gaps in care not covered
by other resources or payers. The Program serves more
than half a million low-income people with HIV/AIDS
in the U.S. each year. Thirty-three percent of those
served by the Ryan White HIV/AIDS Program are uninsured
and 56 percent are underinsured. Ryan White HIV/AIDS
Program services are intended to reduce the use of
more costly emergency services and inpatient care,
increase access to care for underserved populations,
and improve the quality of life for those infected
or affected by the epidemic.
The Ryan White Comprehensive AIDS Resources Emergency
Act was first enacted in August 1990. It was amended
and reauthorized for five years in May 1996 and for
an additional five years in October 2000. The Program
was reauthorized again in December 2006 for three
years as the Ryan White HIV/AIDS Treatment Modernization
Act of 2006.
The Ryan White HIV/AIDS Program demonstrates a comprehensive
and aggressive approach in how government has targeted
dollars toward the development of an effective service
delivery system. By funding and partnering with community
based, non-profit, local and State programs, the Ryan
White HIV/AIDS Program provides primary medical care
and support services; healthcare provider training;
and technical assistance to help funded programs address
implementing the new law and emerging HIV care need.
The HIV/AIDS Bureau requests $2.17 billion for the
Ryan White HIV/AIDS Program. The program’s structure
and distinct components serve very specific purposes.
The FY 2009 Program specific funding request and structure
of each component follow.
- $619 million for Part A which will provide grants
for 22 eligible metropolitan areas (EMAs) and 34
transitional grant areas (TGAs) disproportionately
affected by HIV/AIDS to fund a variety of medical
and support services;
- $1.2 billion for Part B which will provide grants
to 59 States and Territories to improve the quality,
availability, and organization of HIV/AIDS health
care and support services. This includes $815 million
to provide access to FDA approved HIV-related medications
through the AIDS Drug Assistance Program (ADAP)
which is the nation’s prescription drug safety-net
for people living with HIV/AIDS, serving primarily
low-income people who have limited or no access
to needed medications;
- $199 million for Part C which will provide 357
grants directly to service providers (i.e. Federally-qualified
health centers, family planning clinics, rural health
clinics, Indian Health Service facilities; community-based
organizations, and nonprofit faith-based organizations)
to support outpatient HIV early intervention services
and ambulatory care. It will also provide 15 capacity
building grants;
- $74 million for Part D which will provide 93
grants to community based and non-profit private
and public organizations to support family-centered
comprehensive care to HIV-infected women, infants,
children and youth and support to their affected
family members. It also will provide 16 Adolescent
Program grants.
- Part F: Including:
- $29 million for AIDS Education and Training
Center (AETC) grants to organizations to support
education and training of health care providers
through 11 Regional Centers, 130 Local Performance
Sites and 4 National Centers; and
- $13 million for HIV/AIDS Dental Reimbursement
Program, a retrospective payment system providing
reimbursement to dental schools, hospitals with
postdoctoral dental education programs, and
community colleges with dental hygiene programs
for uncompensated costs incurred in providing
oral health treatment to patients with HIV disease;
and for Community-based Dental Partnership Grants
to provide support to dental providers for increased
access to oral health care services for HIV-positive
individuals while providing education and clinical
training for dental care providers, especially
those located in community based settings.
- $25 million for Special Projects of National
Significance (SPNS) funded from the Department PHS
Act evaluation set-asides.
The HIV/AIDS Bureau has continued to demonstrate
outstanding performance by improving access to health
care, improving health outcomes, improving quality
of health care, and promoting efficiency. The Ryan
White Program uses various strategies to achieve its
performance goals, including targeting resources to
high-risk areas, working to assure patient adherence
and compliance, directing outreach and prevention
education and testing to populations at disproportionate
risk for HIV infection, tailoring 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
collaborating with other programs and providers for
referrals to Ryan White service providers.
Improving Access to Health Care:
The Ryan White HIV/AIDS Program works to improve access
to health care by addressing the disparities in access,
treatment, and care for racial/ethnic minorities and
women disproportionately impacted by HIV/AIDS. The
Ryan White HIV/AIDS Program provides HIV/AIDS care
and treatment services to a significantly higher proportion
of racial/ethnic minorities and women than their representation
among AIDS cases 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. In 2006, 72% of the Ryan White HIV/AIDS
Program clients were racial/ethnic minorities. (The
CDC AIDS data for comparison are not available at
the time of this writing.)
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%.
(CDCs AIDS data used for comparison are not available
at the time of this writing.)
Improving Health Outcomes: In 2006,
the AIDS Drug Assistance Program (ADAP) served 157,988
clients through State ADAPs. This can not be compared
with the FY 2006 target because the actual performance
is based on the revised measure using annual data
and the target is based on the former measure utilizing
monthly Program data. The number of ADAP clients served
through State ADAPs annually in 2006 was 10,801 persons
above the 2005 results. About one in four HIV positive
people in care in the U.S. receive their medications
through State ADAPs.
CDC estimates that 1.039 to 1.185 million people
in the United States are living with HIV/AIDS, of
whom an estimated 25 percent are unaware of their
serostatus. In 2005, the number of persons who learned
their serostatus from Ryan White HIV/AIDS Programs
was 572,397, exceeding the target by 7,757 persons.
These efforts demonstrate that the Ryan White HIV/AIDS
Program has made important strides in reaching people
living with HIV/AIDS in the United States who do not
know their serostatus.
Mother-to-child transmission in the U.S. has decreased
dramatically, since its peak in 1992, due to the use
of anti-retroviral therapy which significantly reduces
the risk of transmission from the mother to her baby.
In 2005, 85.3% of HIV-positive pregnant women in Ryan
White HIV/AIDS Programs received anti-retroviral medications.
Improving the Quality of Health Care:
A major focus of the Ryan White HIV/AIDS Program is
to improve the quality of care that its clients receive.
Legislative requirements found in the Ryan White HIV/AIDS
Treatment Modernization Act of 2006 direct grantees
to develop, implement, and monitor clinical quality
management programs to ensure that service providers
adhere to established HIV clinical practices and quality
improvement strategy; and that demographic, clinical,
and health care utilization information is used to
monitor trends in the spectrum of HIV-related illnesses
and the local epidemic. Building on earlier program
efforts, by 2006, 88.6% of Ryan White HIV/AIDS Program-funded
primary medical care providers had implemented a quality
management program, exceeding the target by 18.6 percentage
points.
CD4 cell measurement, a key test used to assess the
functioning of the immune system, helps guide decisions
about when to start HIV treatment and monitors effectiveness
of HIV treatment. Viral load tests measure the amount
of HIV in the blood and are used along with CD4 cell
counts to decide when to start HIV treatment and to
monitor response to therapy. 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.
Promoting Efficiency: State ADAPs
use a variety of strategies to contain costs and these
result in a more effective use of funding, enabling
ADAPs to serve more people. Cost-containment measures
used by ADAPs include: using drug purchasing strategies
like seeking cost recovery through drug rebates and
third party billing; and direct negotiation of pharmaceutical
pricing. ADAPs’ 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.
Program Assessment Rating Tool:
An Office of Management and Budget (OMB) Program Assessment
Rating Tool (PART) reassessment of the Ryan White
HIV/AIDS Program was conducted in 2007 and the Program
received the highest possible rating of Effective.
The review found that the program has had a positive
impact, has strong and effective collaborations with
similar programs, and has demonstrated improved management
and oversight of the use of Federal funds. The Program
is undertaking actions that include: 1) Implementing
the 2006 reauthorization of the Ryan White HIV/AIDS
Program and assuring that new provisions are being
fulfilled appropriately, and 2) Working toward client-level
data reporting by Ryan White HIV/AIDS Program beginning
in 2009 to obtain accurate counts of those served
with Ryan White HIV/AIDS Program funds.
*Funding History
FY 1999 |
$ 1,435,851,000 |
FY 2000 |
$ 1,619,235,000 |
FY 2001 |
$ 1,832,609,000 |
FY 2002 |
$ 1,927,239,000 |
FY 2003 |
$ 2,017,966,000 |
FY 2004 |
$ 2,044,861,000 |
FY 2005 |
$ 2,073,296,000 |
FY 2006 |
$ 2,061,275,000 |
FY 2007 |
$ 2,137,795,000 |
FY 2008 |
$ 2,166,792,000 |
* Includes SPNS
Budget Request
The FY 2009 Request of $2,167,912,000 is
an increase of $1,120,000 over the FY 2008 Enacted
level. This funding will continue to support over
2,300 providers that help half a million individuals
living with HIV/AIDS obtain access to life-sustaining
care and supportive services. The Part A request includes
a decrease of $7,725,000. The FY 2009 Request also
includes an increase of $14,239,000 to support current
Part B program activities and includes an increase
of $6,046,000 to AIDS Drug Assistance Program that
provides life-saving medications for an additional
148 people living with HIV over the FY 2008 target.
The Part C FY 2009 Request is $198,754,000 and the
Part D FY 2009 Request is $73,690,000. Both the Part
C and the Part D Request are the same as the FY 2008
Enacted level. The Part F AIDS Education and Training
Centers FY 2009 Request of $28,700,000 is $5,394,000
less than the FY 2008 Enacted level. This will decrease
the AETC Program’s level of services including
training and technical assistance to HIV/AIDS health
care providers. The Part F Dental Service FY 2009
Request of $12,857,000 is equal to FY 2008 Enacted
level.
In FY 2009, the Program will continue its central
goal of increasing access to care for underserved
populations, and improving the quality of life for
those infected or affected by the epidemic. Some ongoing
challenges faced in meeting performance targets include
the following: many persons are unaware of their serostatus,
persons who know they are infected may be reluctant
to seek HIV/AIDS care, and persons may be unaware
of the availability of Ryan White HIV/AIDS Program
services. To the extent possible, the Program targets
resources to address these challenges.
The Program will continue to appropriately target
racial/ethnic minorities and women because these groups
are disproportionately impacted by HIV/AIDS. For African
Americans and other blacks, HIV/AIDS is a leading
cause of death. With regard to women, data from the
2005 census show that together, black and Hispanic
women represent 24% of all US women. However, women
in these 2 groups accounted for 82% of the estimated
total of AIDS diagnoses for women. The FY 2009 targets
for the proportion of racial/ethnic minorities and
women served in Ryan White HIV/AIDS –funded
programs are 5 percentage points above CDC data.
In FY 2009, the Program will aim to reach the following
additional performance targets. The number of clients
served by ADAPs is predicted to be 158,887 clients.
The FY 2009 target for persons who learn their serostatus
from Ryan White HIV/AIDS programs is 572,397. The
FY 2009 target for the percentage of HIV-positive
pregnant women in Ryan White HIV/AIDS Programs who
receive anti-retroviral medication is 89.3%.
The budget request will also support the Program’s
ongoing efforts to improve the quality of health care.
The FY 2009 target for the percentage of Ryan White
HIV/AIDS Program-funded primary care providers that
will have implemented a quality management program
is 95.7%. The FY 2009 targets for new HIV infected
clients who are tested for CD4 is 87.2% and for viral
load is 83.3%.
In FY 2009, the Ryan White HIV/AIDS Program will
continue to coordinate and collaborate with related
Federal, State, local entities as well as national
AIDS organizations in order to further leverage and
promote efforts to address the unmet care and treatment
needs of persons living with HIV/AIDS who are uninsured
or underinsured. The Program’s work in collaboration
with others has been a key to its success. Federal
partners include the Centers for Disease Control and
Prevention (CDC), the Substance Abuse and Mental Health
Services Administration (SAMHSA), the Center for Medicaid
and Medicare Service, (CMS), Indian Health Service
(IHS), the Department of Housing and Urban Development
(HUD), the National Institutes of Health (NIH), the
Department of Veteran’s Affairs (DVA), and the
Department of Justice (DOJ).
# |
Key Outcomes |
FY 2004 Actual |
FY 2005 Actual |
FY 2006 |
FY 2007 |
FY 2008 Target |
FY 2009 Target |
Out-Year Target |
Target |
Actual |
Target |
Actual |
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. (Baseline – 2005) |
|
412,000/
195,000 |
|
|
|
|
|
|
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). |
DNA a |
72% |
5 percentage points
above CDC datab |
72% |
5 percentage points
above CDC data |
Oct-08 |
5 percentage points
above CDC data |
5 percentage points
above CDC data |
NA c |
# |
Key Outcomes |
FY 2004 Actual |
FY 2005 Actual |
FY 2006 |
FY 2007 |
FY 2008 Target |
FY 2009 Target |
Out-Year Target |
Target |
Actual |
Target |
Actual |
Long-Term
Objective: Expand the Capacity of the Health Care
Safety Net |
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) |
33% |
33% |
5 percentage points
above CDC datab |
33% |
5 percentage points
above CDC data |
Oct-08 |
5 percentage points
above CDC data |
5 percentage points
above CDC data |
NA c |
Long-Term
Objective: Expand the Availability of Health Care,
Particularly to Underserved, Vulnerable, and Special
Needs Populations |
16.2 |
Reduce deaths of persons due to HIV infection.
(Baseline – 2003: 4.7 per 100,000) |
|
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|
|
2014:
3.1 per 100,000 |
# |
Key Outputs |
FY 2004 Actual |
FY 2005 Actual |
FY 2006 |
FY 2007 |
FY 2008 Target/
Est. |
FY 2009 Target/
Est. |
Out-Year
Target/ Est. |
Target/ Est. |
Actual |
Target/ Est. |
Actual |
Long-Term Objective: Expand
the Availability of Health Care, Particularly
to Underserved, Vulnerable, and Special Needs
Populations |
16.II.A.1. |
Number of AIDS Drug Assistance Program (ADAP)
clients served through State ADAPs annually. |
DNA a |
147,187 |
131,808d |
157,988 |
143,339 d |
Jan-09 |
158,739d |
158,887 |
NA c |
16.II.A.2. |
Number of persons who learn their serostatus
from Ryan White HIV/AIDS Programs. |
553,569 |
572,397 |
583,845 |
Feb-08 |
572,397e |
Feb-09 |
572,397e |
572,397 |
NA c |
16.II.A.3. |
Percentage of HIV-positive pregnant women in
Ryan White HIV/AIDS Programs who receive Anti-Retroviral
Medications. |
DNA a |
85.30% |
86.30% |
Feb-08 |
87.30% |
Feb-09 |
88.30% |
89.30% |
NA c |
# |
Key Outputs |
FY 2004 Actual |
FY 2005
Actual |
FY 2006 |
FY 2007 |
FY 2008 Target/
Est. |
FY 2009 Target/
Est. |
Out-Year
Target/ Est. |
Target/ Est. |
Actual |
Target/ Est. |
Actual |
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) |
|
63.70% |
|
|
|
|
|
|
2014:
90% f |
16.III.A.1. |
Percentage of Ryan White HIV/AIDS Program-funded
primary medical care providers that will have
implemented a quality management program. |
DNAa |
85.70% |
70% |
88.60% |
90.7%e |
Aug-08 |
93.2%e |
95.70% |
NA c |
16.III.A.2. |
Proportion of new Ryan White HIV/AIDS Program
HIV-infected clients who are tested for CD4 count
and viral load |
DNAa |
CD4 -83.2%
Viral Load – 79.3% |
CD4-80%
Viral Load – 75% |
CD4-84.9%
Viral Load-82.5% |
CD4-85.2%
Viral Load-81.3%e |
Aug-08 |
CD4-86.2%
Viral Load – 82.3%e |
CD4-87.2%
Viral Load – 83.3% |
NA c |
Efficiency Measure |
16.E. |
Amount of savings by State ADAPs’ participation
in cost-savings strategies on medications.g |
$143.5M |
$275M |
2 percent over FY 05 |
Apr-08 |
1 percent over FY 06 e |
Apr-09 |
1 percent over FY 07e |
1 percent over FY 08 |
NAc |
|
Appropriated Amount ($ Million) |
$2,044.90 |
$2,073.30 |
|
$2,061.30 |
|
$2,137.80 |
$2,166.80 |
$2,167.90 |
|
Notes:
a |
DNA = Data not available. Due to
the aggregate nature of the CADR data and the
way the race/ethnicity questions were 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 |
NA = Not applicable. |
d |
The FY 2006 target is based on number of persons
served at least one quarter of the year, rather
than number of persons served annually. The FY
2007 and FY 2008 targets differ from those shown
in the FY 2008 Congressional Justification to
reflect actual funding levels. |
e |
The FY 2007 and FY 2008 targets differ from
those shown in the FY 2008 Congressional Justification
because targets were reset in the FY 2007 PART
reassessment. |
f |
This target was established during the PART
reassessment, and therefore differs from the previously
reported target. |
g |
Cost-saving strategies are defined as rebates,
third party reimbursements, and direct negotiations
with pharmaceutical companies. |
|