# Presentation: 248499

## Title XXVI of the PHS Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006

- President’s Advisory Committee on HIV/AIDS
- February 27, 2007
- Deborah Parham Hopson, PhD, RN
- Associate Administrator
- DHHS, HRSA, HIV/AIDS Bureau

- © 2005 HMI

## Prior History

- Signed into law in 1990
- Funds first appropriated for FY 1991
- Reauthorized in 1996 for four years
- Reauthorized in 2000 for five years
- Reauthorized in 2006 for three years as the Ryan White HIV/AIDS Treatment Modernization Act (RWHATMA)

## New Law Maintains Purpose

- Primary focus on primary care and support services for individuals living with HIV disease
- Provision of life-extending HIV/AIDS drug therapies
- Persons who lack health insurance and financial resources for their care
- Training, technical assistance, and demonstration projects

## Structural Aspects of the New Law  

- P.L. 109-415
- Signed into Law December 19, 2006
- Three rather than 5 year authorization period
- Sunsets after 2009
- Maintains Title structure, also known as Parts A-D
- Codifies Minority AIDS Initiative (MAI) programs

## Structural Aspects of the New Law

- Part A (Title I) - Eligible Metropolitan Areas and Transitional Grant Areas
- Part B (Title II) - States and Territories, includes AIDS Drug Assistance Program (ADAP)
- Part C (Title III) - Early Intervention Services
- Part D (Title IV) - Women, Infants, Children and Youth
- Part E – General Provisions
- Part F – SPNS, AETCs, Dental, MAI

## Changes in the Ryan White Legislation – Part A (TITLE I)

| EMA Eligibility: >2000 cumulative AIDS cases during most recent 5 years and
> 50,000 population |
| --- |
| N = 22 EMAs in FY2007 |
| Continued EMA Eligibility after FY2007: retain EMA status until fail, for 3 consecutive years, to meet 2 criteria: >2000 cumulative AIDS cases during most recent 5 years and cumulative total of >3000 living AIDS cases in most recent calendar year |
| Transitional Grant Areas (TGAs) Eligibility: 1000-1999 cumulative AIDS cases during most recent 5 years
> 50,000 population |
| N = 34 Transitional Grant Areas in FY2007 including 29 former EMAs and 5 new areas – Baton Rouge, Charlotte, Indianapolis, Memphis and Nashville |
| Continued TGA Eligibility after FY2007: retain TGA status until fail, for 3 consecutive years, to meet 2 criteria: 1000-1999 cumulative AIDS cases during most recent 5 years and cumulative total of >1500 living AIDS cases in most recent calendar year.  |
| EMA and TGA funding based on most recent calendar year of HIV/AIDS data |

## Changes in the Ryan White Legislation – Part A (TITLE I)

| HIV/AIDS data must be used from name-based (i.e. CDC-certified) and code-based jurisdictions for grant awards |
| --- |
| Core medical services
75% of grant spent on core medical services (after 10% deducted for admin and after 5% or $3 million deducted for quality)
Waiver allowed |
| Planning councils required for EMAs and former EMAs
Planning councils optional for 5 new transitional areas (Baton Rouge, Nashville, Charlotte, Memphis, Indianapolis) |
| Formula: Supplemental = 2/3:1/3 |
| MAI funded by competitive application process  |

## Implications of Changes in Part A (Title I) 

- Formula awards – March 1, 2007
- Supplemental awards – April 30, 2007
- MAI awards – August 1, 2007
- Technical assistance to EMAs and TGAs - ongoing

## Changes in the Ryan White Legislation – Part B (TITLE II) - Base

| Formula award based on living HIV/AIDS cases from most recent calendar (CY2005 data will be used for FY2007 grant awards) |
| --- |
| HIV data must be used from name-based (i.e. CDC certified) and code-based jurisdictions for grant awards |
| Core medical services
75% of grant spent on core medical services (after 15% deducted for admin. and after 5% or $3 million deducted for quality)
Waiver allowed |
| All services, including medical care, delivered via consortia deemed support services |
| Emerging Communities – non EMAs, non TGAs with 500-999 cumulative AIDS cases during most recent 5 years; limited to $5 million per FY |
| MAI funded by competitive application process  |
| Competitive supplemental grants to states with “demonstrated need” |

## Changes in the Ryan White Legislation – Part B (TITLE II) - ADAP

| N = 59 (now includes all Pacific jurisdictions) |
| --- |
| Requires Secretary to establish a list of drug classes under which ADAPs must provide therapeutics |
| Formula award based on living HIV/AIDS cases from most recent calendar |
| 5% set aside for supplemental for states with severe need |

## Implications of Changes in Part B (Title II) 

- Base Formula awards – April 1, 2007
- ADAP Formula award – April 1, 2007
- ADAP Supplemental award – June 1, 2007
- MAI awards – August 1, 2007
- State Supplemental – to be determined
- Technical assistance to States and territories - ongoing

## Changes in the Ryan White Legislation – Part C (TITLE III)

| 75% must be spent on Core Medical Services; Waiver allowed
50% must be spent on Early Intervention Services
10% allowed for administrative costs which includes planning and evaluation but excludes clinical quality management
 |
| --- |
| Preference given to areas with high rates of STDs, TB, drug abuse, and hepatitis B and/or C |
| Capacity building - Preference is given to entities that provide primary care services in rural areas or to underserved populations  |

## Changes in the Ryan White Legislation – Part D (TITLE IV)

| 10% Administrative cap 
Indirect costs are not included under the administrative cap |
| --- |
| Provision of information and education on opportunities to participate in HIV/AIDS-related clinical trials |
| Annual review of programs by the Secretary no later than 180 days after the fiscal year |
| GAO Report to be completed on “how funds are used to provide the administrative expenses, indirect costs and services” |

## Changes in the Ryan White Legislation – Part F – SPNS and Dental Programs

| SPNS - Funds programs to:
1) Quickly respond to emerging needs of individuals receiving assistance    under the program; and 
2) Support the development of standard client-level data systems
 |
| --- |
| Dental Programs - No changes from prior law |

## Changes in the Ryan White Legislation – Part F - AETC

| Explicitly adds “and Native Americans” as target group for whom health professionals are trained to treat. |
| --- |
| Training must be provided on treatment for hepatitis B or hepatitis C co-infected individuals |

## Changes in the Ryan White Legislation: General Provisions re Coordination

| Requires Secretary to ensure that HRSA, CDC, SAMHSA and CMS coordinate planning, funding and implementation of Federal HIV programs |
| --- |
| Every 2 years the Secretary is required to prepare and submit to Congress a report on coordination efforts at Federal, State and local levels |
| States must assure that RWHATMA-funded health support services are integrated with other such services, programs are coordinated, and care and prevention services are enhanced |
| Local governments or private nonprofit entities must assure that RWHATMA-funded services are integrated, programs are coordinated, and care and prevention services are enhanced |

## Changes in the Ryan White Legislation: General Provisions re Audits and Other Provisions

| The Secretary must annually select representative samples of RWHATMA program audits, prepare summaries of same and submit these summaries to Congress |
| --- |
| Audits received from the State Part B entity must be posted, in their entirety, on the HRSA website |
| Beginning in FY2009, the Secretary may reduce grant amounts if they fail to prepare audits |
| Every 2 years the GAO must prepare and submit to Congress a report on how RWHATMA funds are expended, how RWHATMA funds increase access to prevention and care, program integration and barriers to care |
| Severity of need index must be developed and submitted to Congress by September 30, 2008 |

## Changes in the Ryan White Legislation: General Provisions re Public Health Emergencies

| During an emergency period and in an emergency area, the Secretary may waive the RWHATMA requirements to improve health and safety of RWHATMA care recipients and the general public |
| --- |
| No more than 5% of funds available under the Part A supplemental and Part B State supplemental may be expended for these public health emergencies |
| If Part A supplemental and Part B State supplemental funds are not spent for public health emergencies during the FY of the emergency, the funds shall be returned to the “original pots” for the Secretary to redistribute |

## Implementation of New RWHATMA

- HRSA has begun to implement the new RWHATMA
- Provisions will be phased in during  the course of FY 2007
- Some provisions are not slated for implementation until future years, including the severity of need index, certain Congressional reports, client level data collection and provisions related to unobligated funds
- HRSA is issuing letters to grantees to reflect the changes in the reauthorized legislation and is providing technical assistance to the grantees

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