Ryan White HIV/AIDS Programs

Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Summary)

Notes:
*   This long-term measure does not have annual targets.
a   CDC’s data for comparison is not available as of this writing.
b   The FY 2007 target is based on number of persons served at least  one quarter of the year, rather than number of persons served annually.
c   Cost-saving strategies are defined as rebates, third party reimbursements, and direct negotiations with pharmaceutical companies.

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 above.  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.  In FY 2007, 72% of clients served in the Ryan White HIV/AIDS – funded programs were racial/ethnic minorities.  (The CDC AIDS data for comparison is not available as of this writing.)  Seventy-two percent (72%) of clients served in Ryan White HIV/AIDS-funded programs in FY 2006 were racial/ethnic minorities, compared to the 63.7% of CDC-reported AIDS cases.  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.  The FY 2009 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.  The proportion of women served by the Ryan White HIV/AIDS Program in 2007 was 33%.  (The CDC AIDS data for comparison is not available as of this writing.)  In 2006, 33% of those clients in the Ryan White HIV/AIDS Program were women, compared to 23% of CDC-reported AIDS cases.  In 2005, 33% of persons served by the Ryan White HIV/AIDS Program were women, compared to 24% of CDC-reported AIDS cases.  The FY 2009 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 2007, the AIDS Drug Assistance Program (ADAP) served 163,927 clients through State ADAPs.  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.  This can not be compared with the FY 2007 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 FY 2006 was 157,988.  The number of ADAP clients served through State ADAPs annually in 2007 was 5,939 persons above the 2006 annual results.  About one in four HIV positive people in care in the U.S. receive their medications through State ADAPs.  The FY 2009 target for clients served through State ADAPs is 142,865.  The ADAP target reflects consideration of increased medical inflation including rising health insurance premiums; the addition of two new drug classes that include drugs requiring patients to have special laboratory testing; the new PHS guidelines concerning starting therapies earlier; and the impact of anticipated changes in the level of state contributions.  The Program’s ADAP Marginal Cost Analysis is used to help inform target setting.

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.

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 2006, the number of persons who learned their serostatus from Ryan White HIV/AIDS Programs was 641,866 exceeding the target by 58,021 persons.  The number of persons learning their serostatus from Ryan White HIV/AIDS Programs in 2005 was 572,397.  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.  Ryan White HIV/AIDS Program dollars are used for HIV testing only when HIV testing is not otherwise available.  The FY 2009 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 anti-retroviral medications.

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 FY 2006 the Ryan White HIV/AIDS Program provided 84.7% of HIV-positive pregnant women in the Ryan White Program with anti-retroviral medication.  This result fell below the target by 1.6 percentage points.  The proportion of Ryan White HIV-positive pregnant women receiving anti-retroviral medications in 2005 was 85.3%.  The slight decrease in the FY 2006 performance is within the expected variation range from year to year.  The FY 2009 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 focus of the Ryan White HIV/AIDS Program is to improve the quality of care that its clients receive.  Legislative requirements 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 strategies; 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.  The proportion of Ryan White HIV/AIDS Program-funded primary care medical providers that had implemented a quality management program by 2007 was 88.8%.  This fell below the target by 1.9 percentage points.  Additionally, the FY 2007 results represent a growth by 0.2 percentage point over the FY 2006 data which indicated that 88.6% of primary care providers had implemented a quality management program.  The FY 2009 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.  CD4 cell measurement is a key test used: to assess the functioning of the immune system, guide decisions about when to start HIV treatment, and monitor 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 2007, the Ryan White HIV/AIDS Program provided CD4 count testing to 83.9% of new clients and viral load testing to 81.2% of these new clients.  This fell short of the target for CD4 tests by 1.3 percentage points and fell below the target of new clients receiving viral load testing by 0.1 percentage point.
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.  The slight decrease in the FY 2007 performance is within the expected variation range from year to year.  The FY 2009 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.

State ADAPs use a variety of strategies to contain costs which results 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 $258 million in 2006, missing the target by $22.5 million.  The amount of savings by State ADAPs participation in cost-saving strategies on medication in 2005 resulted in $275 million is savings and the result of these savings in 2004 was $143.5 million.   The decline in savings from FY 2005 to FY 2006 led to the adjustment of the FY 2009 target to “sustain the FY 2008 results.”