Ryan White HIV/AIDS Overview

Authorizing Legislation: Title XXVI of the Public Health Service Act, as amended.

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

* 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).

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