The Ryan White Comprehensive AIDS Relief Emergency Act (the CARE Act) is the largest source of federal funding for people living with HIV/AIDS in the United States. The CARE Act was first enacted in 1990, and Congress reauthorized the CARE Act in 2000, ensuring that the HIV/AIDS care infrastructure would continue with federal support for an additional five years. For federal fiscal year 2002, Congress appropriated $1.9 billion dollars for HIV/AIDS care and related services through the CARE Act. The U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) administers these funds. The funds reach people living with HIV/AIDS through various funding streams: city and state grants; direct grants to health care providers; and grants specifically allocated for HIV medications, dental care, provider training and education, and special programs.
The AIDS epidemic in the U.S. changed with the introduction of antiretrovirals in 1996. Advances in medical treatment have allowed people living with HIV/AIDS to live healthier, longer lives, and as a result, more people are living longer with HIV before they progress to an AIDS diagnosis. To address this shift in the epidemic, the reauthorization of the CARE Act in 2001 required that funding for Titles I and II be expanded to reflect the incidence of HIV in addition to AIDS. This change is mandated to occur over the next five to seven years, and requires HIV reporting on a national and local level.
The CARE Act consists of five components or Titles. While each Title is directed toward a different aspect of the HIV/AIDS care system, all of the Titles complement each another in order to provide comprehensive services for people living with HIV/AIDS. The following descriptions identify how much money has been appropriated for federal fiscal year 2002 (October 1, 2001 to September 30, 2002).
Title I: Total Funding for Fiscal Year 2002: $619.5 Million
Title I of the CARE Act provides grants to 51 Eligible Metropolitan Areas (EMAs). These cities and localities around the country (including Puerto Rico) are disproportionately affected by HIV/AIDS. To qualify for Title I funding, jurisdictions must have a population of at least 500,000 people with at least 2,000 cumulative AIDS cases reported during the last five years. The funds are administered by planning councils comprised of local residents living with HIV/AIDS as well as social service providers, mental health and substance abuse providers, public health agencies, hospitals and/or health care planning agencies, HIV prevention providers, and housing and homeless service providers. The planning councils identify the needs of the local community and fund various services to meet the needs of local residents living with HIV/AIDS. For example, Title I sub-grantees may provide the following services: outpatient medical and dental care; home hospice care; mental health and substance abuse treatment; transitional housing; non-emergency transportation; nutritional services; and case management.
Title II: Total Funding for Fiscal Year 2002: $977.4 Million
Title II of the CARE Act provides grants to states and U.S. territories through state health departments. These funds are currently distributed based on a formula that estimates the number of people with AIDS in each state. In order to receive funds, each state must have a comprehensive plan for the delivery and organization of HIV/AIDS services. Title II funding supports a similar range of HIV/AIDS services as described above for Title I. These funds, however, can be used to serve individuals living with HIV/AIDS outside the major metropolitan areas, including people living in rural and suburban communities.
Title II of the CARE Act also includes the AIDS Drug Assistance Program (ADAP). ADAP provides antiretrovirals and other HIV-related medication for individuals whose health insurance does not pay for these life-prolonging drugs. There are ADAPs in all fifty states that support an estimated 125,800 individuals living with HIV/AIDS.
Additionally, last year Title II began a new program of grants for Emerging Communities, defined as cities and localities that do not meet the threshold for Title I designation as an Eligible Metropolitan Area but are still experiencing increasing numbers of AIDS cases [between 500 and 1,999 reported AIDS cases in the last five years].
Title III: Total Funding for Fiscal Year 2002: $193.9 Million
Title III supports comprehensive primary health care for people living with HIV/AIDS. Funding can be used to provide the following services: HIV testing; early intervention and outreach; risk reduction counseling; case management; oral health; nutrition; and mental health services. A wide range of providers receive Title III funding throughout forty states, the District of Columbia, and Puerto Rico, including community and migrant health centers, city and/or county health departments, homeless centers, and other community-based organizations.
Title IV: Total Funding for Fiscal Year 2002: $70.9 Million
Title IV funds services for children, youth, and women living with HIV and their families. Grants are provided to public and nonprofit organizations to provide comprehensive health care services, including primary medical care, case management and related social services, and research.
Part F: Total Funding for Fiscal Year 2002: $48.8 Million
Within Part F of the CARE Act, there are three distinct programs: the HIV/AIDS Dental Reimbursement Program, Special Projects of National Significance, and the AIDS Education and Training Centers.
The Dental Reimbursement Program funds oral health care services for people living with HIV/AIDS. The program reimburses dental education programs for the unpaid costs associated with providing services to people living with HIV/AIDS, including diagnostic, preventive, restorative, periodontal, and oral surgery. In 1997, the dental program paid for dental services for 69,000 people living with HIV/AIDS in 103 dental institutions around the United States.
The Special Projects of National Significance (SPNS) supports innovative HIV service delivery models to provide health and social services to underserved populations. SPNSs receive three percent of the funds appropriated to each of the four titles.
The AIDS Education and Training Centers (AETCs) offer experienced HIV providers with training, consultation, and up-to-date information on HIV treatment. These programs are targeted to physicians, nurses, physician assistants, pharmacists, and dentists. The network of 14 regional centers and 70 performance sites enables HIV experts to build professional relationships and expand the network of available HIV services.
The Ryan White CARE Act provides people living with HIV/AIDS with a range of medical and supportive services. As the payer of last resort, the CARE Act is invaluable in filling the gaps in public and private health insurance for people living with HIV/AIDS. The CARE Act has enabled people living with HIV/AIDS to live longer, more productive lives through the provision of a safety net of AIDS care services.