79–006

106TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 106–788

RYAN WHITE CARE ACT AMENDMENTS OF 2000

JULY 25, 2000.—Committed to the Committee of the Whole House on the State of

the Union and ordered to be printed

Mr. BLILEY, from the Committee on Commerce,

submitted the following

R E P O R T

together with

ADDITIONAL VIEWS

[To accompany H.R. 4807]

[Including cost estimate of the Congressional Budget Office]

The Committee on Commerce, to whom was referred the bill

(H.R. 4807) to amend the Public Health Service Act to revise and

extend programs established under the Ryan White Comprehensive

AIDS Resources Emergency Act of 1990, and for other purposes,

having considered the same, report favorably thereon with an

amendment and recommend that the bill as amended do pass.

CONTENTS

Page

Amendment .............................................................................................................. 2

Purpose and Summary ............................................................................................ 22

Background and Need for Legislation .................................................................... 22

Hearings ................................................................................................................... 45

Committee Consideration ........................................................................................ 45

Committee Votes ...................................................................................................... 45

Committee Oversight Findings ............................................................................... 46

Committee on Government Reform Oversight Findings ...................................... 46

New Budget Authority, Entitlement Authority, and Tax Expenditures. ............ 46

Committee Cost Estimate ....................................................................................... 46

Congressional Budget Office Estimate ................................................................... 46

Federal Mandates Statement ................................................................................. 54

Advisory Committee Statement .............................................................................. 54

Constitutional Authority Statement ...................................................................... 54

Applicability to Legislative Branch ........................................................................ 54

2

Section-by-Section Analysis of the Legislation ...................................................... 54

Changes in Existing Law Made by the Bill, as Reported ..................................... 68

Additional Views ...................................................................................................... 114

AMENDMENT

The amendment is as follows:

Strike all after the enacting clause and insert the following:

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘‘Ryan White CARE Act Amendments of 2000’’.

SEC. 2. TABLE OF CONTENTS.

The table of contents for this Act is as follows:

TITLE I—EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES

Subtitle A—HIV Health Services Planning Councils

Sec. 101. Membership of councils.

Sec. 102. Duties of councils.

Sec. 103. Open meetings; other additional provisions.

Subtitle B—Type and Distribution of Grants

Sec. 111. Formula grants.

Sec. 112. Supplemental grants.

Subtitle C—Other Provisions

Sec. 121. Use of amounts.

Sec. 122. Application.

Sec. 123. Review of administrative costs and compensation.

TITLE II—CARE GRANT PROGRAM

Subtitle A—General Grant Provisions

Sec. 201. Priority for women, infants, and children.

Sec. 202. Use of grants.

Sec. 203. Grants to establish HIV care consortia.

Sec. 204. Provision of treatments.

Sec. 205. State application.

Sec. 206. Distribution of funds.

Sec. 207. Supplemental grants for certain States.

Subtitle B—Provisions Concerning Pregnancy and Perinatal Transmission of HIV

Sec. 211. Repeals.

Sec. 212. Grants.

Sec. 213. Study by Institute of Medicine.

Subtitle C—Certain Partner Notification Programs

Sec. 221. Grants for compliant partner notification programs.

TITLE III—EARLY INTERVENTION SERVICES

Subtitle A—Formula Grants for States

Sec. 301. Repeal of program.

Subtitle B—Categorical Grants

Sec. 311. Preferences in making grants.

Sec. 312. Planning and development grants.

Sec. 313. Authorization of appropriations.

Subtitle C—General Provisions

Sec. 321. Provision of certain counseling services.

Sec. 322. Additional required agreements.

TITLE IV—OTHER PROGRAMS AND ACTIVITIES

Subtitle A—Certain Programs for Research, Demonstrations, or Training

Sec. 401. Grants for coordinated services and access to research for women, infants, children, and youth.

Sec. 402. AIDS education and training centers.

Subtitle B—General Provisions in Title XXVI

Sec. 411. Evaluations and reports.

Sec. 412. Data collection through Centers for Disease Control and Prevention.

Sec. 413. Coordination.

Sec. 414. Plan regarding release of prisoners with HIV disease.

Sec. 415. Audits.

Sec. 416. Administrative simplification.

Sec. 417. Authorization of appropriations for parts A and B.

TITLE V—GENERAL PROVISIONS

Sec. 501. Studies by Institute of Medicine.

Sec. 502. Development of rapid HIV test.

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TITLE VI—EFFECTIVE DATE

Sec. 601. Effective date.

TITLE I—EMERGENCY RELIEF FOR AREAS

WITH SUBSTANTIAL NEED FOR SERVICES

Subtitle A—HIV Health Services Planning

Councils

SEC. 101. MEMBERSHIP OF COUNCILS.

(a) IN GENERAL.—Section 2602(b) of the Public Health Service Act (42 U.S.C.

300ff–12(b)) is amended—

(1) in paragraph (1), by striking ‘‘demographics of the epidemic in the eligible

area involved,’’ and inserting ‘‘demographics of the population of individuals

with HIV disease in the eligible area involved,’’; and

(2) in paragraph (2)—

(A) in subparagraph (G), by striking ‘‘or AIDS’’;

(B) in subparagraph (K), by striking ‘‘and’’ at the end;

(C) in subparagraph (L), by striking the period and inserting the following: ‘‘, including but not limited to providers of HIV prevention services;

and’’; and

(D) by adding at the end the following subparagraph:

‘‘(M) representatives of individuals who formerly were Federal, State, or

local prisoners, were released from the custody of the penal system during

the preceding three years, and had HIV disease as of the date on which the

individuals were so released.’’.

(b) CONFLICTS OF INTERESTS.—Section 2602(b)(5) of the Public Health Service Act

(42 U.S.C. 300ff–12(b)(5)) is amended by adding at the end the following subparagraph:

‘‘(C) COMPOSITION OF COUNCIL.—The following applies regarding the

membership of a planning council under paragraph (1):

‘‘(i) Not less than 33 percent of the council shall be individuals who

are receiving HIV-related services pursuant to a grant under section

2601(a), are not officers, employees, or consultants to any entity that

receives amounts from such a grant, and do not represent any such entity, and reflect the demographics of the population of individuals with

HIV disease as determined under paragraph (4)(A). For purposes of the

preceding sentence, an individual shall be considered to be receiving

such services if the individual is a parent of, or a caregiver for, a minor

child who is receiving such services.

‘‘(ii) With respect to membership on the planning council, clause (i)

may not be construed as having any effect on entities that receive

funds from grants under any of parts B through F but do not receive

funds from grants under section 2601(a), on officers or employees of

such entities, or on individuals who represent such entities.’’.

SEC. 102. DUTIES OF COUNCILS.

(a) IN GENERAL.—Section 2602(b)(4) of the Public Health Service Act (42 U.S.C.

300ff–12(b)(4)) is amended—

(1) by redesignating subparagraphs (A) through (E) as subparagraphs (C)

through (G), respectively;

(2) by inserting before subparagraph (C) (as so redesignated) the following

subparagraphs:

‘‘(A) determine the size and demographics of the population of individuals

with HIV disease;

‘‘(B) determine the needs of such population, with particular attention

to—

‘‘(i) individuals with HIV disease who are not receiving HIV-related

services; and

‘‘(ii) disparities in access and services among affected subpopulations

and historically underserved communities;’’;

(3) in subparagraph (C) (as so redesignated), by striking clauses (i) through

(iv) and inserting the following:

‘‘(i) size and demographics of the population of individuals with HIV

disease (as determined under subparagraph (A)) and the needs of such

population (as determined under subparagraph (B));

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‘‘(ii) demonstrated (or probable) cost effectiveness and outcome effectiveness of proposed strategies and interventions, to the extent that

data are reasonably available;

‘‘(iii) priorities of the communities with HIV disease for whom the

services are intended;

‘‘(iv) availability of other governmental and nongovernmental resources to provide HIV-related services to individuals and families with

HIV disease, including the State plan under title XIX of the Social Security Act (relating to the Medicaid program) and the program under

title XXI of such Act (relating to the program for State children’s health

insurance); and

‘‘(v) capacity development needs resulting from disparities in the

availability of HIV-related services in historically underserved communities;’’;

(4) in subparagraph (D) (as so redesignated), by amending the subparagraph

to read as follows:

‘‘(D) develop a comprehensive plan for the organization and delivery of

health and support services described in section 2604 that—

‘‘(i) includes a strategy for identifying individuals with HIV disease

who are not receiving such services and for informing the individuals

of and enabling the individuals to utilize the services, giving particular

attention to eliminating disparities in access and services among affected subpopulations and historically underserved communities, and

including discrete goals, a timetable, and an appropriate allocation of

funds;

‘‘(ii) includes a strategy to coordinate the provision of such services

with programs for HIV prevention and for the prevention and treatment of substance abuse, including programs that provide comprehensive treatment services for such abuse; and

‘‘(iii) is compatible with any State or local plan for the provision of

services to individuals with HIV disease;’’;

(5) in subparagraph (F) (as so redesignated), by striking ‘‘and’’ at the end;

(6) in subparagraph (G) (as so redesignated)—

(A) by striking ‘‘public meetings,’’ and inserting ‘‘public meetings (in accordance with paragraph (7)),’’; and

(B) by striking the period and inserting ‘‘; and’’; and

(7) by adding at the end the following subparagraph:

‘‘(H) coordinate with Federal grantees that provide HIV-related services

within the eligible area.’’.

(b) PROCESS FOR ESTABLISHING ALLOCATION PRIORITIES.—Section 2602 of the Public Health Service Act (42 U.S.C. 300ff–12) is amended by adding at the end the

following subsection:

‘‘(d) PROCESS FOR ESTABLISHING ALLOCATION PRIORITIES.—Promptly after the date

of the submission of the report required in section 501(b) of the Ryan White CARE

Act Amendments of 2000 (relating to the relationship between epidemiological

measures and health care for certain individuals with HIV disease), the Secretary,

in consultation with entities that receive amounts from grants under section 2601(a)

or 2611, shall develop epidemiologic measures—

‘‘(1) for establishing the number of individuals living with HIV disease who

are not receiving HIV-related health services; and

‘‘(2) for carrying out the duties under subsection (b)(4) and section 2617(b).’’.

(c) TRAINING.—Section 2602 of the Public Health Service Act (42 U.S.C. 300ff–12),

as amended by subsection (b) of this section, is amended by adding at the end the

following subsection:

‘‘(e) TRAINING GUIDANCE AND MATERIALS.—The Secretary shall provide to each

chief elected official receiving a grant under 2601(a) guidelines and materials for

training members of the planning council under paragraph (1) regarding the duties

of the council.’’.

SEC. 103. OPEN MEETINGS; OTHER ADDITIONAL PROVISIONS.

Section 2602(b) of the Public Health Service Act (42 U.S.C. 300ff–12(b)) is

amended—

(1) in paragraph (3), by striking subparagraph (C); and

(2) by adding at the end the following paragraph:

‘‘(7) PUBLIC DELIBERATIONS.—With respect to a planning council under paragraph (1), the following applies:

‘‘(A) The council may not be chaired solely by an employee of the grantee

under section 2601(a).

‘‘(B) In accordance with criteria established by the Secretary:

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‘‘(i) The meetings of the council shall be open to the public and shall

be held only after adequate notice to the public.

‘‘(ii) The records, reports, transcripts, minutes, agenda, or other documents which were made available to or prepared for or by the council

shall be available for public inspection and copying at a single location.

‘‘(iii) Detailed minutes of each meeting of the council shall be kept.

The accuracy of all minutes shall be certified to by the chair of the

council.

‘‘(iv) This subparagraph does not apply to any disclosure of information of a personal nature that would constitute a clearly unwarranted

invasion of personal privacy, including any disclosure of medical information or personnel matters.’’.

Subtitle B—Type and Distribution of Grants

SEC. 111. FORMULA GRANTS.

(a) EXPEDITED DISTRIBUTION.—Section 2603(a)(2) of the Public Health Service Act

(42 U.S.C. 300ff–13(a)(2)) is amended in the first sentence by striking ‘‘for each of

the fiscal years 1996 through 2000’’ and inserting ‘‘for a fiscal year’’.

(b) AMOUNT OF GRANT; ESTIMATE OF LIVING CASES.— (1) IN GENERAL.—Section 2603(a)(3)) of the Public Health Service Act (42

U.S.C. 300ff–13(a)(3)) is amended—

(A) in subparagraph (C)(i), by inserting before the semicolon the following: ‘‘, except that (subject to subparagraph (D)), for grants made pursuant to this paragraph for fiscal year 2005 and subsequent fiscal years, the

cases counted for each 12-month period beginning on or after July 1, 2004,

shall be cases of HIV disease (as reported to and confirmed by such Director) rather than cases of acquired immune deficiency syndrome’’; and

(B) in subparagraph (C), in the matter after and below clause (ii)(X)—

(i) in the first sentence, by inserting before the period the following:

‘‘, and shall be reported to the congressional committees of jurisdiction’’;

and

(ii) by adding at the end the following sentence: ‘‘Updates shall as applicable take into account the counting of cases of HIV disease pursuant to clause (i).’’

(2) DETERMINATION OF SECRETARY REGARDING DATA ON HIV CASES.—Section

2603(a)(3)) of the Public Health Service Act (42 U.S.C. 300ff–13(a)(3)) is

amended—

(A) by redesignating subparagraph (D) as subparagraph (E); and

(B) by inserting after subparagraph (C) the following subparagraph:

‘‘(D) DETERMINATION OF SECRETARY REGARDING DATA ON HIV CASES.— ‘‘(i) IN GENERAL.—Not later than July 1, 2004, the Secretary shall determine whether there is data on cases of HIV disease from all eligible

areas (reported to and confirmed by the Director of the Centers for Disease Control and Prevention) sufficiently accurate and reliable for use

for purposes of subparagraph (C)(i). In making such a determination,

the Secretary shall take into consideration the findings of the study

under section 501(b) of the Ryan White CARE Act Amendments of 2000

(relating to the relationship between epidemiological measures and

health care for certain individuals with HIV disease), the fiscal impact

of the use of such data, the impact of the use of such data on the organization and delivery of HIV-related services in eligible areas, and the

fiscal impact of not using such data.

‘‘(ii) EFFECT OF ADVERSE DETERMINATION.—If under clause (i) the Secretary determines that data on cases of HIV disease is not sufficiently

accurate and reliable for use for purposes of subparagraph (C)(i), then

notwithstanding such subparagraph, for any fiscal year prior to fiscal

year 2007 the references in such subparagraph to cases of HIV disease

do not have any legal effect.

‘‘(iii) GRANTS AND TECHNICAL ASSISTANCE REGARDING COUNTING OF

HIV CASES.—Of the amounts appropriated under section 2675 for a fiscal year, the Secretary shall reserve amounts to make grants and provide technical assistance to States and eligible areas with respect to obtaining data on cases of HIV disease to ensure that data on such cases

is available from all States and eligible areas as soon as is practicable

but not later than the beginning of fiscal year 2007.’’.

(c) INCREASES IN GRANT.—Section 2603(a)(4)) of the Public Health Service Act (42

U.S.C. 300ff–13(a)(4)) is amended to read as follows:

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‘‘(4) INCREASES IN GRANT.—

‘‘(A) IN GENERAL.—For each fiscal year in a protection period for an eligible area, the Secretary shall increase the amount of the grant made pursuant to paragraph (2) for the area to ensure that—

‘‘(i) for the first fiscal year in the protection period, the grant is not

less than 98 percent of the amount of the grant made for the eligible

area pursuant to such paragraph for the base year for the protection

period;

‘‘(ii) for any second fiscal year in such period, the grant is not less

than 95.7 percent of the amount of such base year grant;

‘‘(iii) for any third fiscal year in such period, the grant is not less

than 91.1 percent of the amount of the base year grant;

‘‘(iv) for any fourth fiscal year in such period, the grant is not less

than 84.2 percent of the amount of the base year grant; and

‘‘(v) for any fifth or subsequent fiscal year in such period, the grant

is not less than 75 percent of the amount of the base year grant.

‘‘(B) BASE YEAR; PROTECTION PERIOD.—With respect to grants made pursuant to paragraph (2) for an eligible area:

‘‘(i) The base year for a protection period is the fiscal year preceding

the trigger grant-reduction year.

‘‘(ii) The first trigger grant-reduction year is the first fiscal year (after

fiscal year 2000) for which the grant for the area is less than the grant

for the area for the preceding fiscal year.

‘‘(iii) A protection period begins with the trigger grant-reduction year

and continues until the beginning of the first fiscal year for which the

amount of the grant for the area equals or exceeds the amount of the

grant for the base year for the period.

‘‘(iv) Any subsequent trigger grant-reduction year is the first fiscal

year, after the end of the preceding protection period, for which the

amount of the grant is less than the amount of the grant for the preceding fiscal year.’’.

SEC. 112. SUPPLEMENTAL GRANTS.

(a) IN GENERAL.—Section 2603(b)(2) of the Public Health Service Act (42 U.S.C.

300ff–13(b)(2)) is amended—

(1) in the heading for the paragraph, by striking ‘‘DEFINITION’’ and inserting

‘‘AMOUNT OF GRANT’’;

(2) by redesignating subparagraphs (A) through (C) as subparagraphs (B)

through (D), respectively;

(3) by inserting before subparagraph (B) (as so redesignated) the following

subparagraph:

‘‘(A) IN GENERAL.—The amount of each grant made for purposes of this

subsection shall be determined by the Secretary based on a weighting of

factors under paragraph (1), with severe need under subparagraph (B) of

such paragraph counting one-third.’’;

(4) in subparagraph (B) (as so redesignated)—

(A) in clause (ii), by striking ‘‘and’’ at the end;

(B) in clause (iii), by striking the period and inserting a semicolon; and

(C) by adding at the end the following clauses:

‘‘(iv) the current prevalence of HIV disease;

‘‘(v) an increasing need for HIV-related services, including relative

rates of increase in the number of cases of HIV disease; and

‘‘(vi) unmet need for such services, as determined under section

2602(b)(4).’’;

(5) in subparagraph (C) (as so redesignated)—

(A) by striking ‘‘subparagraph (A)’’ each place such term appears and inserting ‘‘subparagraph (B)’’’;

(B) in the second sentence, by striking ‘‘2 years after the date of enactment of this paragraph’’ and inserting ‘‘18 months after the date of the enactment of the Ryan White CARE Act Amendments of 2000’’; and

(C) by inserting after the second sentence the following sentence: ‘‘Such

a mechanism shall be modified to reflect the findings of the study under

section 501(b) of the Ryan White CARE Act Amendments of 2000 (relating

to the relationship between epidemiological measures and health care for

certain individuals with HIV disease).’’; and

(6) in subparagraph (D) (as so redesignated), by striking ‘‘subparagraph (B)’’

and inserting ‘‘subparagraph (C)’’’.

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(b) REQUIREMENTS FOR APPLICATION.—Section 2603(b)(1)(E) of the Public Health

Service Act (42 U.S.C. 300ff–13(b)(1)(E)) is amended by inserting ‘‘youth,’’ after

‘‘children,’’.

(c) CONFORMING AMENDMENT.—Section 2603(b) of the Public Health Service Act

(42 U.S.C. 300ff–13(b)) is amended—

(1) by striking paragraph (4); and

(2) by redesignating paragraph (5) as paragraph (4).

Subtitle C—Other Provisions

SEC. 121. USE OF AMOUNTS.

(a) PRIMARY PURPOSES.—Section 2604(b)(1) of the Public Health Service Act (42

U.S.C. 300ff–14(b)(1)) is amended—

(1) in the matter preceding subparagraph (A), by striking ‘‘HIV-related—’’ and

inserting ‘‘HIV-related services, as follows:’’;

(2) in subparagraph (A)—

(A) by striking ‘‘outpatient’’ and all that follows through ‘‘substance abuse

treatment and’’ and inserting the following: ‘‘Outpatient and ambulatory

health services, including substance abuse treatment,’’; and

(B) by striking ‘‘; and’’ and inserting a period;

(3) in subparagraph (B), by striking ‘‘(B) inpatient case management’’ and inserting ‘‘(C) Inpatient case management’’;

(4) by inserting after subparagraph (A) the following subparagraph:

‘‘(B) Outpatient and ambulatory support services (including case management), to the extent that such services facilitate, support, or sustain the delivery, or benefits of health services for individuals and families with HIV

disease.’’; and

(5) by adding at the end the following:

‘‘(D) Outreach activities that are intended to identify individuals with

HIV disease who are not receiving HIV-related services, and that are—

‘‘(i) necessary to implement the strategy under section 2602(b)(4)(D),

including activities facilitating the access of such individuals to HIVrelated primary care services at entities described in paragraph (3);

‘‘(ii) conducted in a manner consistent with the requirements under

sections 2605(a)(3) and 2651(b)(2); and

‘‘(iii) supplement, and do not supplant, such activities that are carried out with amounts appropriated under section 317.’’.

(b) ADDITIONAL PURPOSES.—Section 2604(b) (42 U.S.C. 300ff–14(b)) of the Public

Health Service Act is amended—

(1) by redesignating paragraph (3) as paragraph (4);

(2) by inserting after paragraph (2) the following:

‘‘(3) EARLY INTERVENTION SERVICES.—

‘‘(A) IN GENERAL.—The purposes for which a grant under section 2601

may be used include providing to individuals with HIV disease early intervention services described in section 2651(b)(2) (including referrals under

subparagraph (C) of such section), subject to subparagraph (B). The entities

through which such services may be provided under the grant include public health departments, emergency rooms, substance abuse and mental

health treatment programs, detoxification centers, detention facilities, clinics regarding sexually transmitted diseases, homeless shelters, HIV disease

counseling and testing sites, health care points of entry specified by States

or eligible areas, federally qualified health centers, and entities described

in section 2652(a).

‘‘(B) CONDITIONS.—With respect to an entity that proposes to provide

early intervention services under subparagraph (A), such subparagraph applies only if the entity demonstrates to the satisfaction of the chief elected

official for the eligible area involved that—

‘‘(i) Federal, State, or local funds are otherwise inadequate for the

early intervention services the entity proposes to provide; and

‘‘(ii) the entity will expend funds pursuant to such subparagraph to

supplement and not supplant other funds available to the entity for the

provision of early intervention services for the fiscal year involved.’’;

and

(3) in paragraph (4) (as so redesignated), by inserting ‘‘youth,’’ after ‘‘children,’’ each place such term appears;

(c) QUALITY MANAGEMENT.—Section 2604 of the Public Health Service Act (42

U.S.C. 300ff–14) is amended—

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(1) by redesignating subsections (c) through (f) as subsections (d) through (g),

respectively; and

(2) by inserting after subsection (b) the following:

‘‘(c) QUALITY MANAGEMENT.— ‘‘(1) REQUIREMENT.—The chief elected official of an eligible area that receives

a grant under this part shall provide for the establishment of a quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are

consistent with the guidelines.

‘‘(2) USE OF FUNDS.—From amounts received under a grant awarded under

this part for a fiscal year, the chief elected official of an eligible area may (in

addition to amounts to which subsection (f)(1) applies) use for activities associated with the quality management program required in paragraph (1) not more

than the lesser of—

‘‘(A) 5 percent of amounts received under the grant; or

‘‘(B) $3,000,000.’’.

SEC. 122. APPLICATION.

Section 2605(a) of the Public Health Service Act (42 U.S.C. 300ff–15(a)) is

amended—

(1) by redesignating paragraphs (3) through (6) as paragraphs (4) through (7),

respectively; and

(2) by inserting after paragraph (2) the following paragraph:

‘‘(3) that entities within the eligible area that receive funds under a grant

under section 2601(a) will maintain relationships with appropriate entities in

the area, including entities described in section 2604(b)(3);’’.

SEC. 123. REVIEW OF ADMINISTRATIVE COSTS AND COMPENSATION.

Each chief elected official of an eligible area (as defined in section 2607 of the

Public Health Service Act) shall ensure that, not later than one year after the date

of the enactment of this Act, the planning council for the eligible area—

(1) conducts a review of the existing, available data on the extent to which

entities in the area that receive amounts from a grant under section 2601(a)

of the Public Health Service Act have from their overall budget expended

amounts for administrative costs (including financial compensation and benefits), expressed as a proportion and indicating the growth in such expenditures,

including a statement of the average amount expended for such costs per client

served and the average amount expended for such costs per client served in providing HIV-related services; and

(2) makes a determination of whether the financial compensation of any officers or employees of such entities exceeds that of the chief elected official of the

eligible area.

TITLE II—CARE GRANT PROGRAM

Subtitle A—General Grant Provisions

SEC. 201. PRIORITY FOR WOMEN, INFANTS, AND CHILDREN.

Section 2611(b) of the Public Health Service Act (42 U.S.C. 300ff–21(b)) is amended by inserting ‘‘youth,’’ after ‘‘children,’’ each place such term appears.

SEC. 202. USE OF GRANTS.

Section 2612 of the Public Health Service Act (42 U.S.C. 300ff–22) is amended—

(1) by striking ‘‘A State may use’’ and inserting ‘‘(a) IN GENERAL.—A State

may use’’; and

(2) by adding at the end the following subsections:

‘‘(b) SUPPORT SERVICES; OUTREACH.—The purposes for which a grant under this

part may be used include delivering or enhancing the following:

‘‘(1) Support services under section 2611(a) (including case management) to

the extent that such services facilitate, support, or sustain the delivery, or benefits of health services for individuals and families with HIV disease.

‘‘(2) Outreach activities that are intended to identify individuals with HIV disease who are not receiving HIV-related services, and that are—

‘‘(A) necessary to implement the strategy under section 2617(b)(4)(B);

‘‘(B) conducted in a manner consistent with the requirement under section 2617(b)(6)(G); and

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‘‘(C) supplement, and do not supplant, such activities that are carried out

with amounts appropriated under section 317.

‘‘(c) EARLY INTERVENTION SERVICES.—

‘‘(1) IN GENERAL.—The purposes for which a grant under this part may be

used include providing to individuals with HIV disease early intervention services described in section 2651(b)(2) (including referrals under subparagraph (C)

of such section), subject to paragraph (2). The entities through which such services may be provided under the grant include public health departments, emergency rooms, substance abuse and mental health treatment programs, detoxification centers, detention facilities, clinics regarding sexually transmitted diseases, homeless shelters, HIV disease counseling and testing sites, health care

points of entry specified by States or eligible areas, federally qualified health

centers, and entities described in section 2652(a).

‘‘(2) CONDITIONS.—With respect to an entity that proposes to provide early

intervention services under paragraph (1), such paragraph applies only if the

entity demonstrates to the satisfaction of the State involved that—

‘‘(A) Federal, State, or local funds are otherwise inadequate for the early

intervention services the entity proposes to provide; and

‘‘(B) the entity will expend funds pursuant to such paragraph to supplement and not supplant other funds available to the entity for the provision

of early intervention services for the fiscal year involved.

‘‘(d) QUALITY MANAGEMENT.—

‘‘(1) REQUIREMENT.—Each State that receives a grant under this part shall

provide for the establishment of a quality management program to assess the

extent to which HIV health services provided to patients under the grant are

consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infection, and as applicable, to

develop strategies for ensuring that such services are consistent with the guidelines.

‘‘(2) USE OF FUNDS.—From amounts received under a grant awarded under

this part for a fiscal year, the State may (in addition to amounts to which section 2618(c)(5) applies) use for activities associated with the quality management program required in paragraph (1) not more than the lesser of—

‘‘(A) 5 percent of amounts received under the grant; or

‘‘(B) $3,000,000.’’.

SEC. 203. GRANTS TO ESTABLISH HIV CARE CONSORTIA.

Section 2613 of the Public Health Service Act (42 U.S.C. 300ff–23) is amended—

(1) in subsection (b)(1)—

(A) in subparagraph (A), by inserting before the semicolon the following:

‘‘, particularly those experiencing disparities in access and services and

those who reside in historically underserved communities’’; and

(B) in subparagraph (B), by inserting after ‘‘by such consortium’’ the following: ‘‘is consistent with the comprehensive plan under 2617(b)(4) and’’;

(2) in subsection (c)(1)—

(A) in subparagraph (D), by striking ‘‘and’’ after the semicolon at the end;

(B) in subparagraph (E), by striking the period and inserting ‘‘; and’’;

(C) by adding at the end the following subparagraph:

‘‘(F) demonstrates that adequate planning occurred to address disparities

in access and services and historically underserved communities.’’; and

(3) in subsection (c)(2)—

(A) in subparagraph (B), by striking ‘‘and’’ after the semicolon;

(B) in subparagraph (C), by striking the period and inserting ‘‘; and’’; and

(C) by inserting after subparagraph (C) the following subparagraph:

‘‘(D) entities described in section 2602(b)(2).’’.

SEC. 204. PROVISION OF TREATMENTS.

Section 2616 of the Public Health Service Act (42 U.S.C. 300ff–26) is amended by

adding at the end the following subsection:

‘‘(e) USE OF HEALTH INSURANCE AND PLANS.—In carrying out subsection (a), a

State may expend a grant under this part to provide the therapeutics described in

such subsection by paying on behalf of individuals with HIV disease the costs of

purchasing or maintaining health insurance or plans whose coverage includes a full

range of such therapeutics and appropriate primary care services.’’.

SEC. 205. STATE APPLICATION.

(a) DETERMINATION OF SIZE AND NEEDS OF POPULATION; COMPREHENSIVE PLAN.—

Section 2617(b) of the Public Health Service Act (42 U.S.C. 300ff–27(b)) is

amended—

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(1) by redesignating paragraphs (2) through (4) as paragraphs (4) through (6),

respectively;

(2) by inserting after paragraph (1) the following paragraphs:

‘‘(2) a determination of the size and demographics of the population of individuals with HIV disease in the State;

‘‘(3) a determination of the needs of such population, with particular attention

to—

‘‘(A) individuals with HIV disease who are not receiving HIV-related services; and

‘‘(B) disparities in access and services among affected subpopulations and

historically underserved communities;’’; and

(3) in paragraph (4) (as so redesignated)—

(A) by striking ‘‘comprehensive plan for the organization’’ and inserting

‘‘comprehensive plan that describes the organization’’;

(B) by striking ‘‘, including—’’ and inserting ‘‘, and that—’’;

(C) by redesignating subparagraphs (A) through (C) as subparagraphs (D)

through (F), respectively;

(D) by inserting before subparagraph (C) the following subparagraphs:

‘‘(A) establishes priorities for the allocation of funds within the State

based on—

‘‘(i) size and demographics of the population of individuals with HIV

disease (as determined under paragraph (2)) and the needs of such population (as determined under paragraph (3));

‘‘(ii) availability of other governmental and nongovernmental resources to provide HIV-related services to individuals and families with

HIV disease;

‘‘(iii) capacity development needs resulting from disparities in the

availability of HIV-related services in historically underserved communities and rural communities; and

‘‘(iv) the efficiency of the administrative mechanism of the State for

rapidly allocating funds to the areas of greatest need within the State;

‘‘(B) includes a strategy for identifying individuals with HIV disease who

are not receiving such services and for informing the individuals of and enabling the individuals to utilize the services, giving particular attention to

eliminating disparities in access and services among affected subpopulations and historically underserved communities, and including discrete

goals, a timetable, and an appropriate allocation of funds;

‘‘(C) includes a strategy to coordinate the provision of such services with

programs for HIV prevention and for the prevention and treatment of substance abuse, including programs that provide comprehensive treatment

services for such abuse;’’;

(E) in subparagraph (D) (as redesignated by subparagraph (C) of this

paragraph), by inserting ‘‘describes’’ before ‘‘the services and activities’’;

(F) in subparagraph (E) (as so redesignated), by inserting ‘‘provides’’ before ‘‘a description’’; and

(G) in subparagraph (F) (as so redesignated), by inserting ‘‘provides’’ before ‘‘a description’’.

(b) PUBLIC PARTICIPATION.—Section 2617(b) of the Public Health Service Act, as

amended by subsection (a) of this section, is amended—

(1) in paragraph (5), by striking ‘‘HIV’’ and inserting ‘‘HIV disease’’; and

(2) in paragraph (6), by amending subparagraph (A) to read as follows:

‘‘(A) the public health agency that is administering the grant for the State

engages in a public advisory planning process, including public hearings,

that includes the participants under paragraph (5), and entities described

in section 2602(b)(2), in developing the comprehensive plan under paragraph (4) and commenting on the implementation of such plan;’’.

(c) HEALTH CARE RELATIONSHIPS.—Section 2617(b) of the Public Health Service

Act, as amended by subsection (a) of this section, is amended in paragraph (6)—

(1) in subparagraph (E), by striking ‘‘and’’ at the end;

(2) in subparagraph (F), by striking the period and inserting ‘‘; and’’; and

(3) by adding at the end the following subparagraph:

‘‘(G) entities within areas in which activities under the grant are carried

out will maintain relationships with appropriate entities in the area, including entities described in section 2612(c);’’.

SEC. 206. DISTRIBUTION OF FUNDS.

(a) MINIMUM ALLOTMENT.— Section 2618(b)(1)(A)(i) of the Public Health Service

Act (42 U.S.C. 300ff–28(b)(1)(A)(i)) is amended—

(1) in subclause (I), by striking ‘‘$100,000’’ and inserting ‘‘$200,000’’; and

11

(2) in subclause (II), by striking ‘‘$250,000’’ and inserting ‘‘$500,000’’.

(b) AMOUNT OF GRANT; ESTIMATE OF LIVING CASES.—Section 2618(b)(2) of the

Public Health Service Act (42 U.S.C. 300ff–28(b)(2)) is amended—

(1) in subparagraph (D)(i), by inserting before the semicolon the following: ‘‘,

except that (subject to subparagraph (E)), for grants made pursuant to this

paragraph for fiscal year 2005 and subsequent fiscal years, the cases counted

for each 12-month period beginning on or after July 1, 2004, shall be cases of

HIV disease (as reported to and confirmed by such Director) rather than cases

of acquired immune deficiency syndrome’’;

(2) by redesignating subparagraphs (E) through (H) as subparagraphs (F)

through (I), respectively; and

(3) by inserting after subparagraph (D) the following subparagraph:

‘‘(E) DETERMINATION OF SECRETARY REGARDING DATA ON HIV CASES.—If

under 2603(a)(3)(D)(i) the Secretary determines that data on cases of HIV

disease is not sufficiently accurate and reliable, then notwithstanding subparagraph (D) of this paragraph, for any fiscal year prior to fiscal year 2007

the references in such subparagraph to cases of HIV disease do not have

any legal effect.’’.

(c) INCREASES IN FORMULA AMOUNT.—Section 2618(b) of the Public Health Service

Act (42 U.S.C. 300ff–28(b)) is amended—

(1) in paragraph (1)(A)(ii), by inserting before the semicolon the following:

‘‘and then, as applicable, increased under paragraph (2)(H)’’; and

(2) in paragraph (2)—

(A) in subparagraph (A)(i), by striking ‘‘subparagraph (H)’’ and inserting

‘‘subparagraphs (H) and (I)’’; and

(B) in subparagraph (H) (as redesignated by subsection (b)(2) of this section), by amending the subparagraph to read as follows:

‘‘(H) LIMITATION.—

‘‘(i) IN GENERAL.—The Secretary shall ensure that the amount of a

grant awarded to a State or territory under section 2611 for a fiscal

year is not less than—

‘‘(I) with respect to fiscal year 2001, 99 percent;

‘‘(II) with respect to fiscal year 2002, 98 percent;

‘‘(III) with respect to fiscal year 2003, 97 percent;

‘‘(IV) with respect to fiscal year 2004, 96 percent; and

‘‘(V) with respect to fiscal year 2005, 95 percent;

of the amount such State or territory received for fiscal year 2000

under such section. In administering this subparagraph, the Secretary

shall, with respect to States or territories that will under such section

receive grants in amounts that exceed the amounts that such States received under such section for fiscal year 2000, proportionally reduce

such amounts to ensure compliance with this subparagraph. In making

such reductions, the Secretary shall ensure that no such State receives

less than that State received for fiscal year 2000.

‘‘(ii) RATABLE REDUCTION.—If the amount appropriated under section

2677 for a fiscal year and available for grants under section 2611 is less

than the amount appropriated and available under such section for fiscal year 2000, the limitation contained in clause (i) shall be reduced by

a percentage equal to the percentage of the reduction in such amounts

appropriated and available.’’.

(d) TERRITORIES.—Section 2618(b)(1)(B) of the Public Health Service Act (42

U.S.C. 300ff–28(b)(1)(B)) is amended by inserting ‘‘the greater of $50,000 or’’ after

‘‘shall be’’.

(e) SEPARATE TREATMENT DRUG GRANTS.—Section 2618(b)(2) of the Public Health

Service Act, as amended by subsection (b)(3) of this section, is amended in subparagraph (I)—

(1) by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively;

(2) by striking ‘‘(I) APPROPRIATIONS’’ and all that follows through ‘‘With respect to’’ and inserting the following:

‘‘(I) APPROPRIATIONS FOR TREATMENT DRUG PROGRAM.—

‘‘(i) FORMULA GRANTS.—With respect to’’;

(3) in subclause (I) of clause (i) (as designated by paragraphs (1) and (2)), by

striking ‘‘100 percent’’ and inserting ‘‘98 percent’’; and

(4) by adding at the end the following clause:

‘‘(ii) SUPPLEMENTAL TREATMENT DRUG GRANTS.—

‘‘(I) IN GENERAL.—With respect to the fiscal year involved, if

under section 2677 an appropriations Act provides an amount exclusively for carrying out section 2616, and such amount is not less

than the amount so provided for the preceding fiscal year, the SecVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00011 Fmt 6659 Sfmt 6621 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
12

retary shall reserve 2 percent of such amount for making grants

to States whose population of individuals with HIV disease has, as

determined by the Secretary, a need for quantities of therapeutics

described in section 2616(a) greater than the quantities available

pursuant to clause (i). Such a grant is available for purposes of obtaining such therapeutics. The Secretary shall carry out this clause

as a program of discretionary grants, and not as a program of formula grants.

‘‘(II) DISTRIBUTION OF GRANTS.—The Secretary shall disburse all

amounts under grants under subclause (I) for a fiscal year not later

than 240 days after the date on which the amount referred to in

such subclause with respect to section 2616 becomes available.

‘‘(III) REQUIREMENT OF MATCHING FUNDS.—A condition for receiving a grant under subclause (I) is that the State agree to make

available (directly or through donations from public or private entities) non-Federal contributions toward the costs of obtaining the

therapeutics involved in an amount that is not less than 25 percent

of such costs (determined in the same manner as under

2617(d)(2)(A)).’’.

(f) TECHNICAL AMENDMENT.—Section 2618(b)(3)(B) of the Public Health Service

Act (42 U.S.C. 300ff–28(b)(3)(B)) is amended by striking ‘‘and the Republic of the

Marshall Islands’’ and inserting ‘‘the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, and only for purposes of

paragraph (1) the Commonwealth of Puerto Rico’’.

SEC. 207. SUPPLEMENTAL GRANTS FOR CERTAIN STATES.

Subpart I of part B of title XXVI of the Public Health Service Act (42 U.S.C.

300ff–11 et seq.) is amended—

(1) by striking section 2621; and

(2) by inserting after section 2620 the following section:

‘‘SEC. 2621. SUPPLEMENTAL GRANTS.

‘‘(a) IN GENERAL.—From amounts available pursuant to subsection (d) for a fiscal

year, the Secretary shall make grants to States that meet the conditions to receive

grants under section 2611, and that have one or more eligible communities, for the

purpose of providing in such communities comprehensive services of the type described in section 2612(a) to supplement the development and care activities, primary care, and support services otherwise provided in such communities by the

State under a grant under section 2611.

‘‘(b) ELIGIBLE COMMUNITY.—For purposes of this section, the term ‘eligible community’ means a geographic area that—

‘‘(1) is not within any eligible area as defined in section 2607; and

‘‘(2) has a severe need for supplemental financial assistance to combat the

HIV epidemic, according to criteria developed by the Secretary in consultation

with the States, including evidence of underserved or rural areas or both.

‘‘(c) APPLICATION.—A grant under subsection (a) may be made to a State if the

State submits to the Secretary, as part of the State application submitted under section 2617, such information as required to apply for funds under this section as determined by the Secretary in consultation with the States.

‘‘(d) FUNDING.—

‘‘(1) IN GENERAL.—For the purpose of making grants under subsection (a) for

a fiscal year, the Secretary shall reserve 50 percent of the amount specified in

paragraph (2).

‘‘(2) INCREASES IN PART B FUNDING.—

‘‘(A) IN GENERAL.—For purposes of paragraph (1), the amount specified in

this paragraph is the amount by which the amount appropriated under section 2677 for the fiscal year involved and available for carrying out part B

is an increase over the amount so appropriated and available for the preceding fiscal year, subject to subparagraphs (B) and (C).

‘‘(B) INITIAL ALLOCATION YEAR.—The allocation under paragraph (1) shall

not be made until the first fiscal year for which the amount appropriated

under section 2677 for the fiscal year involved and available for carrying

out part B is an increase of not less than $20,000,000 over the amount so

appropriated and available for fiscal year 2000, subject to subparagraph

(C).

‘‘(C) EXCLUSION REGARDING SEPARATE TREATMENT DRUG GRANTS.—Each

determination under subparagraph (A) or (B) of the amount appropriated

under section 2677 for a fiscal year and available for carrying out part B

shall be made without regard to any amount to which section

2618(b)(2)(I)(i) applies.’’.

13

Subtitle B—Provisions Concerning Pregnancy and

Perinatal Transmission of HIV

SEC. 211. REPEALS.

Subpart II of part B of title XXVI of the Public Health Service Act (42 U.S.C.

300ff–33 et seq.) is amended—

(1) in section 2626, by striking each of subsections (d) through (f); and

(2) by striking section 2627.

SEC. 212. GRANTS.

(a) IN GENERAL.—Section 2625(c) of the Public Health Service Act (42 U.S.C.

300ff–33) is amended—

(1) in paragraph (1), by inserting at the end the following subparagraph:

‘‘(F) Making available to pregnant women with HIV disease, and to the

infants of women with such disease, treatment services for such disease in

accordance with applicable recommendations of the Secretary.’’;

(2) by amending paragraph (2) to read as follows:

‘‘(2) FUNDING.—

‘‘(A) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out

this subsection, there are authorized to be appropriated $30,000,000 for

each of the fiscal years 2001 through 2005. Amounts made available under

section 2677 for carrying out this part are not available for carrying out

this section unless otherwise authorized.

‘‘(B) ALLOCATIONS FOR CERTAIN STATES.—

‘‘(i) IN GENERAL.—Of the amounts appropriated under subparagraph

(A) for a fiscal year in excess of $10,000,000, the Secretary shall reserve

the applicable percentage under clause (ii) for making grants under

paragraph (1) to States that under law (including under regulations or

the discretion of State officials) have—

‘‘(I) a requirement that all newborn infants born in the State be

tested for HIV disease; or

‘‘(II) a requirement that newborn infants born in the State be

tested for HIV disease in circumstances in which the attending obstetrician for the birth does not know the HIV status of the mother

of the infant.

‘‘(ii) APPLICABLE PERCENTAGE.—For purposes of clause (i), the applicable amount for a fiscal year is as follows:

‘‘(I) For fiscal year 2001, 25 percent.

‘‘(II) For fiscal year 2002, 50 percent.

‘‘(III) For fiscal year 2003, 50 percent.

‘‘(IV) For fiscal year 2004, 75 percent.

‘‘(V) For fiscal year 2005, 75 percent.

‘‘(C) CERTAIN PROVISIONS.—With respect to grants under paragraph (1)

that are made with amounts reserved under subparagraph (B) of this paragraph:

‘‘(i) Such a grant may not be made in an amount exceeding

$4,000,000.

‘‘(ii) If pursuant to clause (i) or pursuant to an insufficient number

of qualifying applications for such grants (or both), the full amount reserved under subparagraph (B) for a fiscal year is not obligated, the requirement under such subparagraph to reserve amounts ceases to

apply.’’; and

(3) by adding at the end the following paragraph:

‘‘(4) MAINTENANCE OF EFFORT.—A condition for the receipt of a grant under

paragraph (1) is that the State involved agree that the grant will be used to

supplement and not supplant other funds available to the State to carry out the

purposes of the grant.’’.

(b) SPECIAL FUNDING RULE FOR FISCAL YEAR 2001.—

(1) IN GENERAL.—If for fiscal year 2001 the amount appropriated under paragraph (2)(A) of section 2625(c) of the Public Health Service Act is less than

$14,000,000—

(A) the Secretary of Health and Human Services shall, for the purpose

of making grants under paragraph (1) of such section, reserve from the

amount specified in paragraph (2) of this subsection an amount equal to the

difference between $14,000,000 and the amount appropriated under paragraph (2)(A) of such section for such fiscal year;

14

(B) the amount so reserved shall, for purposes of paragraph (2)(B)(i) of

such section, be considered to have been appropriated under paragraph

(2)(A) of such section; and

(C) the percentage specified in paragraph (2)(B)(ii)(I) of such section is

deemed to be 50 percent.

(2) ALLOCATION FROM INCREASES IN FUNDING FOR PART B.—For purposes of

paragraph (1), the amount specified in this paragraph is the amount by which

the amount appropriated under section 2677 of the Public Health Service Act

for fiscal year 2001 and available for grants under section 2611 of such Act is

an increase over the amount so appropriated and available for fiscal year 2000.

SEC. 213. STUDY BY INSTITUTE OF MEDICINE.

Subpart II of part B of title XXVI of the Public Health Service Act (42 U.S.C.

300ff–33 et seq.) is amended by adding at the end the following section:

‘‘SEC. 2630. RECOMMENDATIONS FOR REDUCING INCIDENCE OF PERINATAL TRANSMISSION.

‘‘(a) STUDY BY INSTITUTE OF MEDICINE.— ‘‘(1) IN GENERAL.—The Secretary shall request the Institute of Medicine to

enter into an agreement with the Secretary under which such Institute conducts

a study to provide the following:

‘‘(A) For the most recent fiscal year for which the information is available,

a determination of the number of newborn infants with HIV born in the

United States with respect to whom the attending obstetrician for the birth

did not know the HIV status of the mother.

‘‘(B) A determination for each State of any barriers, including legal barriers, that prevent or discourage an obstetrician from making it a routine

practice to offer pregnant women an HIV test and a routine practice to test

newborn infants for HIV disease in circumstances in which the obstetrician

does not know the HIV status of the mother of the infant.

‘‘(C) Recommendations for each State for reducing the incidence of cases

of the perinatal transmission of HIV, including recommendations on removing the barriers identified under subparagraph (B).

If such Institute declines to conduct the study, the Secretary shall enter into

an agreement with another appropriate public or nonprofit private entity to conduct the study.

‘‘(2) REPORT.—The Secretary shall ensure that, not later than 18 months after

the effective date of this section, the study required in paragraph (1) is completed and a report describing the findings made in the study is submitted to

the appropriate committees of the Congress, the Secretary, and the chief public

health official of each of the States.

‘‘(b) PROGRESS TOWARD RECOMMENDATIONS.—Each State shall comply with the

following (as applicable to the fiscal year involved):

‘‘(1) For fiscal year 2004, the State shall submit to the Secretary a report describing the actions taken by the State toward meeting the recommendations

specified for the State under subsection (a)(1)(C).

‘‘(2) For fiscal year 2005 and each subsequent fiscal year—

‘‘(A) the State shall make reasonable progress toward meeting such recommendations; or

‘‘(B) if the State has not made such progress—

‘‘(i) the State shall cooperate with the Director of the Centers for Disease Control and Prevention in carrying out activities toward meeting

the recommendations; and

‘‘(ii) the State shall submit to the Secretary a report containing a description of any barriers identified under subsection (a)(1)(B) that continue to exist in the State; as applicable, the factors underlying the continued existence of such barriers; and a description of how the State

intends to reduce the incidence of cases of the perinatal transmission

of HIV.

‘‘(c) SUBMISSION OF REPORTS TO CONGRESS.—The Secretary shall submit to the appropriate committees of the Congress each report received by the Secretary under

subsection (b)(2)(B)(ii).’’.

Subtitle C—Certain Partner Notification

Programs

SEC. 221. GRANTS FOR COMPLIANT PARTNER NOTIFICATION PROGRAMS.

Part B of title XXVI of the Public Health Service Act (42 U.S.C. 300ff–21 et seq.)

is amended by adding at the end the following subpart:

15

‘‘Subpart III—Certain Partner Notification Programs

‘‘SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS.

‘‘(a) IN GENERAL.—In the case of States whose laws or regulations are in accordance with subsection (b), the Secretary, subject to subsection (c)(2), may make

grants to the States for carrying out programs to provide partner counseling and

referral services.

‘‘(b) DESCRIPTION OF COMPLIANT STATE PROGRAMS.—For purposes of subsection

(a), the laws or regulations of a State are in accordance with this subsection if under

such laws or regulations (including programs carried out pursuant to the discretion

of State officials) the following policies are in effect:

‘‘(1) The State requires that the public health officer of the State carry out

a program of partner notification to inform partners of individuals with HIV

disease that the partners may have been exposed to the disease.

‘‘(2)(A) In the case of a health entity that provides for the performance on an

individual of a test for HIV disease, or that treats the individual for the disease,

the State requires, subject to subparagraph (B), that the entity confidentially

report the positive test results to the State public health officer in a manner

recommended and approved by the Director of the Centers for Disease Control

and Prevention, together with such additional information as may be necessary

for carrying out such program.

‘‘(B) The State may provide that the requirement of subparagraph (A) does

not apply to the testing of an individual for HIV disease if the individual underwent the testing through a program designed to perform the test and provide

the results to the individual without the individual disclosing his or her identity

to the program. This subparagraph may not be construed as affecting the requirement of subparagraph (A) with respect to a health entity that treats an

individual for HIV disease.

‘‘(3) The program under paragraph (1) is carried out in accordance with the

following:

‘‘(A) Partners are provided with an appropriate opportunity to learn that

the partners have been exposed to HIV disease, subject to subparagraph

(B).

‘‘(B) The State does not inform partners of the identity of the infected individuals involved.

‘‘(C) Counseling and testing for HIV disease are made available to the

partners and to infected individuals, and such counseling includes information on modes of transmission for the disease, including information on prenatal and perinatal transmission and preventing transmission.

‘‘(D) Counseling of infected individuals and their partners includes the

provision of information regarding therapeutic measures for preventing and

treating the deterioration of the immune system and conditions arising

from the disease, and the provision of other prevention-related information.

‘‘(E) Referrals for appropriate services are provided to partners and infected individuals, including referrals for support services and legal aid.

‘‘(F) Notifications under subparagraph (A) are provided in person, unless

doing so is an unreasonable burden on the State.

‘‘(G) There is no criminal or civil penalty on, or civil liability for, an infected individual if the individual chooses not to identify the partners of the

individual, or the individual does not otherwise cooperate with such program.

‘‘(H) The failure of the State to notify partners is not a basis for the civil

liability of any health entity who under the program reported to the State

the identity of the infected individual involved.

‘‘(I) The State provides that the provisions of the program may not be

construed as prohibiting the State from providing a notification under subparagraph (A) without the consent of the infected individual involved.

‘‘(4) The State annually reports to the Director of the Centers for Disease

Control and Prevention the number of individuals from whom the names of

partners have been sought under the program under paragraph (1), the number

of such individuals who provided the names of partners, and the number of

partners so named who were notified under the program.

‘‘(5) The State cooperates with such Director in carrying out a national program of partner notification, including the sharing of information between the

public health officers of the States.

‘‘(c) REPORTING SYSTEM FOR CASES OF HIV DISEASE.—

‘‘(1) PREFERENCE IN MAKING GRANTS THROUGH FISCAL YEAR 2003.—In making

grants under subsection (a) for each of the fiscal years 2001 through 2003, the

16

Secretary shall give preference to States whose reporting systems for cases of

HIV disease produce data on such cases that is sufficiently accurate and reliable

for use for purposes of section 2618(b)(2)(D)(i).

‘‘(2) ELIGIBILITY CONDITION AFTER FISCAL YEAR 2003.—For fiscal year 2004 and

subsequent fiscal years, a State may not receive a grant under subsection (a)

unless the reporting system of the State for cases of HIV disease produces data

on such cases that is sufficiently accurate and reliable for purposes of section

2618(b)(2)(D)(i).

‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this

section, there are authorized to be appropriated $30,000,000 for fiscal year 2001,

and such sums as may be necessary for each of the fiscal years 2002 through 2005.’’.

TITLE III—EARLY INTERVENTION SERVICES

Subtitle A—Formula Grants for States

SEC. 301. REPEAL OF PROGRAM.

Subpart I of part C of title XXVI of the Public Health Service Act (42 U.S.C.

300ff–41 et seq.) is repealed.

Subtitle B—Categorical Grants

SEC. 311. PREFERENCES IN MAKING GRANTS.

Section 2653 of the Public Health Service Act (42 U.S.C. 300ff–53) is amended by

adding at the end the following subsection:

‘‘(d) UNDERSERVED AND RURAL AREAS.—Of the applicants who qualify for preference under this section, the Secretary shall give preference to applicants that will

expend the grant under section 2651 to provide early intervention under such section in rural areas or in areas that are underserved with respect to such services.’’.

SEC. 312. PLANNING AND DEVELOPMENT GRANTS.

(a) IN GENERAL.—Section 2654(c)(1) of the Public Health Service Act (42 U.S.C.

300ff–54(c)(1)) is amended by striking ‘‘planning grants’’ and all that follows and inserting the following: ‘‘planning grants to public and nonprofit private entities for

purposes of—

‘‘(A) enabling such entities to provide HIV early intervention services; and

‘‘(B) assisting the entities in expanding their capacity to provide HIV-related health services, including early intervention services, in low-income

communities and affected subpopulations that are underserved with respect

to such services (subject to the condition that a grant pursuant to this subparagraph may not be expended to purchase or improve land, or to purchase, construct, or permanently improve, other than minor remodeling,

any building or other facility).’’.

(b) AMOUNT; DURATION.—Section 2654(c) of the Public Health Service Act (42

U.S.C. 300ff–54(c)) is further amended—

(1) by redesignating paragraph (4) as paragraph (5); and

(2) by inserting after paragraph (3) the following:

‘‘(4) AMOUNT AND DURATION OF GRANTS.—

‘‘(A) EARLY INTERVENTION SERVICES.—A grant under paragraph (1)(A)

may be made in an amount not to exceed $50,000.

‘‘(B) CAPACITY DEVELOPMENT.—

‘‘(i) AMOUNT.—A grant under paragraph (1)(B) may be made in an

amount not to exceed $150,000.

‘‘(ii) DURATION.—The total duration of a grant under paragraph

(1)(B), including any renewal, may not exceed 3 years.’’.

(c) INCREASE IN LIMITATION.—Section 2654(c)(5) of the Public Health Service Act

(42 U.S.C. 300ff–54(c)(5)), as redesignated by subsection (b), is amended by striking

‘‘1 percent’’ and inserting ‘‘5 percent’’.

SEC. 313. AUTHORIZATION OF APPROPRIATIONS.

Section 2655 of the Public Health Service Act (42 U.S.C. 300ff–55) is amended by

striking ‘‘in each of’’ and all that follows and inserting ‘‘for each of the fiscal years

2001 through 2005.’’.

17

Subtitle C—General Provisions

SEC. 321. PROVISION OF CERTAIN COUNSELING SERVICES.

Section 2662(c)(3) of the Public Health Service Act (42 U.S.C. 300ff–62(c)(3)) is

amended—

(1) in the matter preceding subparagraph (A), by striking ‘‘counseling on—’’

and inserting ‘‘counseling—’’;

(2) in each of subparagraphs (A), (B), and (D), by inserting ‘‘on’’ after the subparagraph designation; and

(3) in subparagraph (C)—

(A) by striking ‘‘(C) the benefits’’ and inserting ‘‘(C)(i) that explains the

benefits’’; and

(B) by inserting after clause (i) (as designated by subparagraph (A) of this

paragraph) the following clause:

‘‘(ii) that emphasizes it is the duty of infected individuals to disclose their

infected status to their sexual partners and their partners in the sharing

of hypodermic needles; that provides advice to infected individuals on the

manner in which such disclosures can be made; and that emphasizes that

it is the continuing duty of the individuals to avoid any behaviors that will

expose others to HIV;

SEC. 322. ADDITIONAL REQUIRED AGREEMENTS.

Section 2664(g) of the Public Health Service Act (42 U.S.C. 300ff–64(g)) is

amended—

(1) in paragraph (3)—

(A) by striking ‘‘7.5 percent’’ and inserting ‘‘10 percent’’; and

(B) by striking ‘‘and’’ after the semicolon at the end;

(2) in paragraph (4), by striking the period and inserting ‘‘; and’’; and

(3) by adding at the end the following paragraph:

‘‘(5) the applicant will provide for the establishment of a quality management

program to assess the extent to which medical services funded under this title

that are provided to patients are consistent with the most recent Public Health

Service guidelines for the treatment of HIV disease and related opportunistic

infections and that improvements in the access to and quality of medical services are addressed.’’.

TITLE IV—OTHER PROGRAMS AND ACTIVITIES

Subtitle A—Certain Programs for Research,

Demonstrations, or Training

SEC. 401. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH.

Section 2671 of the Public Health Service Act (42 U.S.C. 300ff–71) is amended—

(1) in subsection (b)—

(A) in paragraph (1), by striking subparagraphs (C) and (D) and inserting

the following:

‘‘(C) The applicant will demonstrate linkages to research and how access

to such research is being offered to patients.’’; and

(B) by striking paragraphs (3) and (4);

(2) in subsection (g), by adding at the end the following: ‘‘In addition, the Secretary, in coordination with the Director of such Institutes, shall examine the

distribution and availability of appropriate HIV-related research projects with

respect to grantees under subsection (a) for purposes of enhancing and expanding HIV-related research, especially within communities that are underrepresented with respect to such projects.’’;

(3) in subsection (f)—

(A) by striking the subsection heading and designation and inserting the

following:

‘‘(f) ADMINISTRATION.— ‘‘(1) APPLICATION.—’’; and

(B) by adding at the end the following paragraph:

‘‘(2) QUALITY MANAGEMENT PROGRAM.—A grantee under this section shall implement a quality management program.’’; and

(4) in subsection (j), by striking ‘‘1996 through 2000’’ and inserting ‘‘2001

through 2005’’.

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SEC. 402. AIDS EDUCATION AND TRAINING CENTERS.

(a) SCHOOLS; CENTERS.—

(1) IN GENERAL.—Section 2692(a)(1) of the Public Health Service Act (42

U.S.C. 300ff–111(a)(1)) is amended—

(A) in subparagraph (A)—

(i) by striking ‘‘training’’ and inserting ‘‘to train’’;

(ii) by striking ‘‘and including’’ and inserting ‘‘, including’’; and

(iii) by inserting before the semicolon the following: ‘‘, and including

(as applicable to the type of health professional involved), prenatal and

other gynecological care for women with HIV disease’’;

(B) in subparagraph (B), by striking ‘‘and’’ after the semicolon at the end;

(C) in subparagraph (C), by striking the period and inserting ‘‘; and’’; and

(D) by adding at the end the following:

‘‘(D) to develop protocols for the medical care of women with HIV disease,

including prenatal and other gynecological care for such women.’’.

(2) DISSEMINATION OF TREATMENT GUIDELINES; MEDICAL CONSULTATION ACTIVITIES.—Not later than 90 days after the date of the enactment of this Act,

the Secretary of Health and Human Services shall issue and begin implementation of a strategy for the dissemination of HIV treatment information to health

care providers and patients.

(b) DENTAL SCHOOLS.—Section 2692(b) of the Public Health Service Act (42 U.S.C.

300ff–111(b)) is amended—

(1) by amending paragraph (1) to read as follows:

‘‘(1) IN GENERAL.—

‘‘(A) GRANTS.—The Secretary may make grants to dental schools and programs described in subparagraph (B) to assist such schools and programs

with respect to oral health care to patients with HIV disease.

‘‘(B) ELIGIBLE APPLICANTS.—For purposes of this subsection, the dental

schools and programs referred to in this subparagraph are dental schools

and programs that were described in section 777(b)(4)(B) as such section

was in effect on the day before the date of enactment of the Health Professions Education Partnerships Act of 1998 (Public Law 105–392) and in addition dental hygiene programs that are accredited by the Commission on

Dental Accreditation.’’;

(2) in paragraph (2), by striking ‘‘777(b)(4)(B)’’ and inserting ‘‘the section referred to in paragraph (1)(B)’’; and

(3) by inserting after paragraph (4) the following paragraph:

‘‘(5) COMMUNITY-BASED CARE.—The Secretary may make grants to dental

schools and programs described in paragraph (1)(B) that partner with community-based dentists to provide oral health care to patients with HIV disease in

unserved areas. Such partnerships shall permit the training of dental students

and residents and the participation of community dentists as adjunct faculty.’’.

(c) AUTHORIZATION OF APPROPRIATIONS.—

(1) SCHOOLS; CENTERS.—Section 2692(c)(1) of the Public Health Service Act

(42 U.S.C. 300ff–111(c)(1)) is amended by striking ‘‘fiscal years 1996 through

2000’’ and inserting ‘‘fiscal years 2001 through 2005’’.

(2) DENTAL SCHOOLS.—Section 2692(c)(2) of the Public Health Service Act (42

U.S.C. 300ff–111(c)(2)) is amended to read as follows:

‘‘(2) DENTAL SCHOOLS.—

‘‘(A) IN GENERAL.—For the purpose of grants under paragraphs (1)

through (4) of subsection (b), there are authorized to be appropriated such

sums as may be necessary for each of the fiscal years 2001 through 2005.

‘‘(B) COMMUNITY-BASED CARE.—For the purpose of grants under subsection (b)(5), there are authorized to be appropriated such sums as may

be necessary for each of the fiscal years 2001 through 2005.’’.

Subtitle B—General Provisions in Title XXVI

SEC. 411. EVALUATIONS AND REPORTS.

Section 2674(c) of the Public Health Service Act (42 U.S.C. 300ff–74(c)) is amended by striking ‘‘1991 through 1995’’ and inserting ‘‘2001 through 2005’’.

SEC. 412. DATA COLLECTION THROUGH CENTERS FOR DISEASE CONTROL AND PREVENTION.

Part D of title XXVI of the Public Health Service Act (42 U.S.C. 300ff–71 et seq.)

is amended—

(1) by redesignating section 2675 as section 2675A; and

(2) by inserting after section 2674 the following section:

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‘‘SEC. 2675. DATA COLLECTION.

‘‘For the purpose of collecting and providing data for program planning and evaluation activities under this title, there are authorized to be appropriated to the Secretary (acting through the Director of the Centers for Disease Control and Prevention) such sums as may be necessary for each of the fiscal years 2001 through 2005.

Such authorization of appropriations is in addition to other authorizations of appropriations that are available for such purpose.’’.

SEC. 413. COORDINATION.

Section 2675A of the Public Health Service Act, as redesignated by section 412

of this Act, is amended—

(1) by amending subsection (a) to read as follows:

‘‘(a) REQUIREMENT.—The Secretary shall ensure that the Health Resources and

Services Administration, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, and the Health Care Financing Administration coordinate the planning, funding, and implementation of

Federal HIV programs to enhance the continuity of care and prevention services for

individuals with HIV disease or those at risk of such disease. The Secretary shall

consult with other Federal agencies, including the Department of Veterans Affairs,

as needed and utilize planning information submitted to such agencies by the States

and entities eligible for support.’’;

(2) by redesignating subsections (b) and (c) as subsections (c) and (d), respectively;

(3) by inserting after subsection (b) the following subsection:

‘‘(b) REPORT.—The Secretary shall biennially prepare and submit to the appropriate committees of the Congress a report concerning the coordination efforts at the

Federal, State, and local levels described in this section, including a description of

Federal barriers to HIV program integration and a strategy for eliminating such

barriers and enhancing the continuity of care and prevention services for individuals

with HIV disease or those at risk of such disease.’’; and

(4) in each of subsections (c) and (d) (as redesignated by paragraph (2) of this

section), by inserting ‘‘and prevention services’’ after ‘‘continuity of care’’ each

place such term appears.

SEC. 414. PLAN REGARDING RELEASE OF PRISONERS WITH HIV DISEASE.

Section 2675A of the Public Health Service Act, as amended by section 413(2) of

this Act, is amended by adding at the end the following subsection:

‘‘(e) RECOMMENDATIONS REGARDING RELEASE OF PRISONERS.—After consultation

with the Attorney General and the Director of the Bureau of Prisons, with States,

with eligible areas under part A, and with entities that receive amounts from grants

under part A or B, the Secretary, consistent with the coordination required in subsection (a), shall develop a plan for the medical case management of and the provision of support services to individuals who were Federal or State prisoners and had

HIV disease as of the date on which the individuals were released from the custody

of the penal system. The Secretary shall submit the plan to the Congress not later

than two years after the date of the enactment of the Ryan White CARE Act

Amendments of 2000.’’.

SEC. 415. AUDITS.

Part D of title XXVI of the Public Health Service Act, as amended by section 412

of this Act, is amended by inserting after section 2675A the following section:

‘‘SEC. 2675B. AUDITS.

‘‘For fiscal year 2002 and subsequent fiscal years, the Secretary may reduce the

amounts of grants under this title to a State or political subdivision of a State for

a fiscal year if, with respect to such grants for the second preceding fiscal year, the

State or subdivision fails to prepare audits in accordance with the procedures of section 7502 of title 31, United States Code. The Secretary shall annually select representative samples of such audits, prepare summaries of the selected audits, and

submit the summaries to the Congress.’’.

SEC. 416. ADMINISTRATIVE SIMPLIFICATION.

Part D of title XXVI of the Public Health Service Act, as amended by section 415

of this Act, is amended by inserting after section 2675B the following section:

‘‘SEC. 2675C. ADMINISTRATIVE SIMPLIFICATION REGARDING PARTS A AND B.

‘‘(a) COORDINATED DISBURSEMENT.—After consultation with the States, with eligible areas under part A, and with entities that receive amounts from grants under

part A or B, the Secretary shall develop a plan for coordinating the disbursement

of appropriations for grants under part A with the disbursement of appropriations

for grants under part B in order to assist grantees and other recipients of amounts

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from such grants in complying with the requirements of such parts. The Secretary

shall submit the plan to the Congress not later than 18 months after the date of

the enactment of the Ryan White CARE Act Amendments of 2000. Not later than

two years after the date on which the plan is so submitted, the Secretary shall complete the implementation of the plan, notwithstanding any provision of this title

that is inconsistent with the plan.

‘‘(b) BIENNIAL APPLICATIONS.—After consultation with the States, with eligible

areas under part A, and with entities that receive amounts from grants under part

A or B, the Secretary shall make a determination of whether the administration of

parts A and B by the Secretary, and the efficiency of grantees under such parts in

complying with the requirements of such parts, would be improved by requiring that

applications for grants under such parts be submitted biennially rather than annually. The Secretary shall submit such determination to the Congress not later than

two years after the date of the enactment of the Ryan White CARE Act Amendments of 2000.

‘‘(c) APPLICATION SIMPLIFICATION.—After consultation with the States, with eligible areas under part A, and with entities that receive amounts from grants under

part A or B, the Secretary shall develop a plan for simplifying the process for applications under parts A and B. The Secretary shall submit the plan to the Congress

not later than 18 months after the date of the enactment of the Ryan White CARE

Act Amendments of 2000. Not later than two years after the date on which the plan

is so submitted, the Secretary shall complete the implementation of the plan, notwithstanding any provision of this title that is inconsistent with the plan.’’.

SEC. 417. AUTHORIZATION OF APPROPRIATIONS FOR PARTS A AND B.

Section 2677 of the Public Health Service Act (42 U.S.C. 300ff–77) is amended to

read as follows:

‘‘SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

‘‘(a) PART A.—For the purpose of carrying out part A, there are authorized to be

appropriated such sums as may be necessary for each of the fiscal years 2001

through 2005.

‘‘(b) PART B.—For the purpose of carrying out part B, there are authorized to be

appropriated such sums as may be necessary for each of the fiscal years 2001

through 2005.’’.

TITLE V—GENERAL PROVISIONS

SEC. 501. STUDIES BY INSTITUTE OF MEDICINE.

(a) STATE SURVEILLANCE SYSTEMS ON PREVALENCE OF HIV.—The Secretary of

Health and Human Services (referred to in this section as the ‘‘Secretary’’) shall request the Institute of Medicine to enter into an agreement with the Secretary under

which such Institute conducts a study to provide the following:

(1) A determination of whether the surveillance system of each of the States

regarding the human immunodeficiency virus provides for the reporting of cases

of infection with the virus in a manner that is sufficient to provide adequate

and reliable information on the number of such cases and the demographic

characteristics of such cases, both for the State in general and for specific geographic areas in the State.

(2) A determination of whether such information is sufficiently accurate for

purposes of formula grants under parts A and B of title XXVI of the Public

Health Service Act.

(3) With respect to any State whose surveillance system does not provide adequate and reliable information on cases of infection with the virus, recommendations regarding the manner in which the State can improve the system.

(b) RELATIONSHIP BETWEEN EPIDEMIOLOGICAL MEASURES AND HEALTH CARE FOR

CERTAIN INDIVIDUALS WITH HIV DISEASE.—

(1) IN GENERAL.—The Secretary shall request the Institute of Medicine to

enter into an agreement with the Secretary under which such Institute conducts

a study concerning the appropriate epidemiological measures and their relationship to the financing and delivery of primary care and health-related support

services for low-income, uninsured, and under-insured individuals with HIV disease.

(2) ISSUES TO BE CONSIDERED.—The Secretary shall ensure that the study

under paragraph (1) considers the following:

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(A) The availability and utility of health outcomes measures and data for

HIV primary care and support services and the extent to which those measures and data could be used to measure the quality of such funded services.

(B) The effectiveness and efficiency of service delivery (including the quality of services, health outcomes, and resource use) within the context of a

changing health care and therapeutic environment, as well as the changing

epidemiology of the epidemic, including determining the actual costs, potential savings, and overall financial impact of modifying the program under

title XIX of the Social Security Act to establish eligibility for medical assistance under such title on the basis of infection with the human immunodeficiency virus rather than providing such assistance only if the infection

has progressed to acquired immune deficiency syndrome.

(C) Existing and needed epidemiological data and other analytic tools for

resource planning and allocation decisions, specifically for estimating severity of need of a community and the relationship to the allocations process.

(D) Other factors determined to be relevant to assessing an individual’s

or community’s ability to gain and sustain access to quality HIV services.

(c) OTHER ENTITIES.—If the Institute of Medicine declines to conduct a study

under this section, the Secretary shall enter into an agreement with another appropriate public or nonprofit private entity to conduct the study.

(d) REPORT.—The Secretary shall ensure that—

(1) not later than three years after the date of the enactment of this Act, the

study required in subsection (a) is completed and a report describing the findings made in the study is submitted to the appropriate committees of the Congress; and

(2) not later than two years after the date of the enactment of this Act, the

study required in subsection (b) is completed and a report describing the findings made in the study is submitted to such committees.

SEC. 502. DEVELOPMENT OF RAPID HIV TEST.

(a) EXPANSION, INTENSIFICATION, AND COORDINATION OF RESEARCH AND OTHER

ACTIVITIES.—

(1) IN GENERAL.—The Director of NIH shall expand, intensify, and coordinate

research and other activities of the National Institutes of Health with respect

to the development of reliable and affordable tests for HIV disease that can rapidly be administered and whose results can rapidly be obtained (in this section

referred to a ‘‘rapid HIV test’’).

(2) REPORT TO CONGRESS.—The Director of NIH shall periodically submit to

the appropriate committees of Congress a report describing the research and

other activities conducted or supported under paragraph (1).

(3) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this

subsection, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2001 through 2005.

(b) PREMARKET REVIEW OF RAPID HIV TESTS.—

(1) IN GENERAL.—Not later than 90 days after the date of the enactment of

this Act, the Secretary, in consultation with the Director of the Centers for Disease Control and Prevention and the Commissioner of Food and Drugs, shall

submit to the appropriate committees of the Congress a report describing the

progress made towards, and barriers to, the premarket review and commercial

distribution of rapid HIV tests. The report shall—

(A) assess the public health need for and public health benefits of rapid

HIV tests, including the minimization of false positive results through the

availability of multiple rapid HIV tests;

(B) make recommendations regarding the need for the expedited review

of rapid HIV test applications submitted to the Center for Biologics Evaluation and Research and, if such recommendations are favorable, specify criteria and procedures for such expedited review; and

(C) specify whether the barriers to the premarket review of rapid HIV

tests include the unnecessary application of requirements—

(i) necessary to ensure the efficacy of devices for donor screening to

rapid HIV tests intended for use in other screening situations; or

(ii) for identifying antibodies to HIV subtypes of rare incidence in the

United States to rapid HIV tests intended for use in screening situations other than donor screening.

(c) GUIDELINES OF CENTERS FOR DISEASE CONTROL AND PREVENTION.—Promptly

after commercial distribution of a rapid HIV test begins, the Secretary, acting

through the Director of the Centers for Disease Control and Prevention, shall establish or update guidelines that include recommendations for States, hospitals, and

other appropriate entities regarding the ready availability of such tests for adminisVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00021 Fmt 6659 Sfmt 6621 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
22

tration to pregnant women who are in labor or in the late stage of pregnancy and

whose HIV status is not known to the attending obstetrician.

TITLE VI—EFFECTIVE DATE

SEC. 601. EFFECTIVE DATE.

This Act and the amendments made by this Act take effect October 1, 2000, or

upon the date of the enactment of this Act, whichever occurs later.

PURPOSE AND SUMMARY

The Ryan White CARE Act Amendments of 2000 reauthorizes

programs providing for the comprehensive health care of Americans suffering from HIV/AIDS and prevention programs to prevent

the spread of HIV.

BACKGROUND AND NEED FOR LEGISLATION

Acquired Immunodeficiency Syndrome (AIDS) cases were first reported in the United States in 1981. In the two decades since, more

than 700,000 persons in the United States have been diagnosed

with AIDS. The General Accounting Office (GAO) recently estimated that by the end of 1998, 300,000 persons in the United

States were living with AIDS, and that as many as hundreds of

thousands of people in this country are infected with the human

immunodeficiency virus (HIV), but have not yet progressed to

AIDS.

Because persons with AIDS faced problems obtaining insurance

coverage and access to primary care and support, the Congress responded in 1990 by passing the Ryan White Comprehensive AIDS

Resources Emergency (CARE) Act (P.L. 101–381). The framework

of that Act, as passed, continues in force today.

Title I of the Act provides relief to eligible metropolitan areas

(EMAs) disproportionately impacted by AIDS. By fiscal year (FY)

1991, there were 16 EMAs receiving CARE Act Title I funding.

Currently, as of FY2000, there are 51 EMAs. Title I relief is provided through formula and supplemental grants to be used for case

management and comprehensive treatment services, among other

things. Such grants are intended to supplement, not supplant,

State funding, and have the express purpose of delivering or enhancing HIV-related outpatient and ambulatory health and support

services. These service include case management, substance abuse

and mental health treatment, comprehensive treatment services,

and inpatient case management services that prevent unnecessary

hospitalization or that expedite discharges.

As originally enacted in 1990, a community was entitled to be an

EMA if the area had more than 2,000 cases of AIDS, or if the cumulative per capita incidence of AIDS exceeded one quarter of one

percent. Under the Ryan White CARE Act Amendments of 1996

(P.L. 104–186), this was changed so that areas could qualify for

funding under Title I if the area has a population of 500,000 or

more individuals, and the area has reported to the Director of the

Centers for Disease Control and Prevention (CDC) a cumulative

total of more than 2,000 cases of AIDS for the most recent five calendar years.

Title I funding is, generally, equally divided amongst formula

and supplemental grants. Formula grants are distributed to EMAs

23

according to a complex distribution factor, taking into account the

estimated living number of AIDS cases in the EMA. The estimated

living number of AIDS cases in an EMA is determined by the number of AIDS cases reported to, and confirmed by, the CDC in the

most recent ten year period, multiplied (on a yearly basis) by a percentage developed by the Secretary of the Department of Health

and Human Services. Title I supplemental grants are awarded

based upon severe need, though these grants have been awarded

historically in a way which results in a doubling of the Title I formula amount.

One important exception must be noted. The 1990 CARE Act distributed formula funds based partially upon the historical number

of AIDS cases the EMA had experienced, irrespective of whether

the disease sufferers were still alive. The 1996 CARE Act Amendments altered this to allocate funds based upon living number of

AIDS cases. Because the change from historic incidences of AIDS

to estimated living AIDS cases per EMA could have caused significant disruptions in funding received by certain EMAs, the 1996

CARE Act Amendments contained a ‘‘hold harmless’’ clause. According to this provision, no EMA could lose more than five percent, over five years, from the EMA’s FY1995 Title I formula grant.

To fund the ‘‘hold harmless’’ provision, the amount of Title I supplemental grant funds available to all EMAs is reduced accordingly.

Title I grants are made to the chief elected official of the city or

county in the EMA that administers the health agency providing

services to the greatest number of persons with AIDS. This chief

elected official must establish or designate an HIV health services

planning council to establish priorities for care delivery according

to Federal guidelines, in order to receive Title I funds. Members of

the councils must reflect the demographics of the epidemic in the

EMA, and it shall include representatives of health care providers;

community-based organizations serving affected populations and

AIDS service organizations; affected communities, including people

with HIV disease or AIDS, and historically underserved groups and

subpopulations; mental health and substance abuse providers, and

others. The council may not be directly involved in the administration of any Title I grant.

Title II funds provide formula grants to states and territories for

comprehensive care services including home and community-based

health care and support services. States use such funds to provide

services directly or through contracts with HIV care consortia. Title

II grants are also used to provide health insurance coverage for

low-income persons through Health Insurance Continuation Programs and drug treatments for individuals with HIV and AIDS

who have limited or no coverage from private insurance or Medicaid through AIDS Drug Assistance Programs (ADAPs). Prior to

FY1996, States determined the amount of their Title II funds they

would dedicate to ADAPs. In FY1996, Congress began appropriating ADAP-targeted funds under Title II.

Grants are awarded to States based upon a weighted formula

that accounts for two factors: (1) the estimated number of living

AIDS cases in the State; and (2) the estimated number of living

AIDS cases in the State who are not in a Title I EMA. States with

more than 1% of the total AIDS cases reported nationally must

24

contribute State matching funds based on a formula, and grants

may not be made to any State that does not make a good faith effort to notify a spouse of an HIV-infected patient that the spouse

should seek testing.

Further, Title II provides up to $10 million for States which certify that they have in effect regulations or measures to adopt CDC

guidelines concerning HIV virus counseling and voluntary testing

for pregnant women. Priority is given to States that have the greatest proportion of HIV seroprevalance among child bearing women,

as determined by the CDC.

Early intervention services are provided for under Title III of the

CARE Act. Under this, public and private nonprofit entities already

providing primary care services to low-income and medically underserved populations compete for grants to provide HIV testing, risk

reduction counseling, case management, outreach, medical evaluation, transmission prevention, oral health, nutritional and mental

health services, and clinical care. Community health centers, homeless programs, local health departments, family planning programs,

hemophilia diagnostic and treatment centers, as well as other nonprofit community-based programs all compete for Title III grants.

When enacted in 1990, Title IV authorized a number of different

HIV-related programs, but the only one for which funds were appropriated was pediatric demonstration grants. In the 1996 CARE

Act Amendments, this funded program was replaced with a program of grants for coordinated services and access to research for

women, infants, children and youth. Such grants provide opportunities for women, infants, children and youth to be voluntary participants in research of potential clinical benefit to individuals with

HIV and AIDS. Such individuals are provided access to health care

on an outpatient basis, case management, referrals, transportation,

child care, and other services which enable participation.

Other programs under the CARE Act which have been funded include special projects of national significance for the care and treatment of individuals with HIV/AIDS, AIDS Education and Training

Centers program (AETC), and the AIDS Dental Reimbursement

program.

Funding Fairness. The Committee has amended and enhanced

the CARE Act to respond to significant changes in the HIV/AIDS

epidemic. It is important to the Committee that no eligible metropolitan area lose its ability to provide services authorized under the

CARE Act. At the same time, it is equally important to the Committee that no EMA receive significantly more Title I formula funding on a per case basis than other similarly-situated EMAs.

It is the Committee’s intention that, over time, each EMA should

receive Title I formula funds in proportion to its estimated number

of living HIV cases. The GAO has reported, however, that presently

one EMA, the San Francisco EMA, receives dramatically more Title

I funding on a per case basis than any other EMA. For example,

GAO reports that in FY 1999 San Francisco spent $5,598 per AIDS

case, while the other 50 EMAs spent between $2,509 and $3,132

per AIDS case. More specifically, GAO reported that the San Francisco EMA receives roughly 80% more per in Title I grant funds per

AIDS case than other EMAs.

25

26

A few have defended this disparity by stating that per patient

cost is higher than other places because the costs of care in services

in the Bay Area is so inflated. But even if CARE Act money were

adjusted for funding the cost of providing medical care (it presently

is not), San Francisco still receives far more than any other EMA

per capita. The accompanying graph uses the Medicare hospital

cost wage index cost adjuster on the per capita Title I formula and

discretionary grant money used in chart 1. Even with these adjustments, it is clear that the San Francisco EMA still gets the most

of all EMAs. With similar cost structures as San Francisco, Oakland and San Jose in the Bay Area join New York at the bottom

of Title I funding.

27

28

The present disparity in funding results from the way EMAs

were funded under Title I when the CARE Act was enacted in

1990. Originally, EMAs were funded based upon the cumulative

number of AIDS cases the EMA experienced. In 1996, Title I formula funding was altered to compensate EMAs based upon the estimated number of living AIDS cases in the EMA, rather than the

cumulative caseload of living and dead AIDS cases. So that certain

EMAs would not find their Title I formula funding dramatically decreased, a hold harmless provision was included in the reauthorization limiting funding cuts to no more than five percent, over five

years, from the 1995 Title I formula amount.

The GAO reports that presently only the San Francisco EMA

benefits from this hold harmless provision, thus explaining the disparity in funding. During the July 11, 2000 hearing before the Subcommittee on Health and Environment, the GAO acknowledged

that a reason for this is that San Francisco’s basis of funding, due

to the hold harmless, still compensates the EMA for individuals

who have long ago died.

To ensure that per case funding is more equitable, H.R. 4807 reforms the hold harmless provision which limits funding reductions

to EMAs. According to the provision in this bill, no EMA would experience a reduction greater than 25% of its base year formula allocation over the next five fiscal years. Such a regime would still

leave the San Francisco EMA with more Title I formula funds on

a per case basis than any other EMA, while still alleviating some

of the unfair funding disparities.

As a way to protect State funding provided by Title II, the legislation contains a hold harmless provision which ensures that no

State will see more than a one percent cut in Title II formula funds

per fiscal year. This reflects a continuation of present law. It is important to note that no State has benefitted from this provision

since its enactment.

The Committee intends that Title I supplemental awards are not

intended to be allocated on the basis of formula grant allocations.

Instead, such supplemental awards are to be directed to those eligible areas with ‘‘severe need,’’ or the greatest or expanding public

health challenges in confronting the epidemic. The Committee has

included additional factors to be considered in the assessment of severe need, including the current prevalence of HIV/AIDS, and the

degree of increasing and unmet needs for services. Additionally, the

Committee believes that syphilis, hepatitis B and hepatitis C

should be regarded as important co-morbidities to HIV/AIDS.

It is the Committee’s strong view that HRSA’s Bureau of HIV/

AIDS should employ standard, quantitative measures to the maximum extent possible in lieu of narrative self-reporting when

awarding supplemental awards. The Committee renews the Bureau’s obligation to develop in a timely manner a mechanism for

determining severe need upon the basis of national, quantitative

incidence data. In this regard, the Committee recognizes that adequate and reliable data on HIV prevalence may not be uniformly

available in all eligible areas on the date of enactment. The Committee also notes that ‘‘HIV disease’’ under the CARE Act encompasses both persons living with AIDS as well as persons diagnosed

as HIV positive who have not developed AIDS.

29

Just as importantly, for the first time the CARE Act will recognize the need for Title II supplemental grants with the passage of

H.R. 4807. These grants are intended for areas, other than EMAs,

experiencing a severe need for supplemental financial assistance.

Like with Title I supplemental awards, it is the Committee’s intention that Title II supplemental awards should not be allocated in

proportion to formula awards, but rather on the basis of demonstrated severe need.

The Committee intends that preference should be given to shift

Title III grants to addressing the needs of rural areas and underserved areas. This preference is intended to further shift CARE Act

programs towards eliminating disparities in access and services

among affected subpopulations and historically underserved communities.

The Committee strongly supports the use of Title I funds to conduct outreach activities to identify individuals with HIV/AIDS who

are not receiving services, and get them under medical care and

treatment. President Reagan’s HIV Commission concluded that

‘‘early diagnosis of HIV infection is essential’’ because HIV infection

‘‘can be treated more effectively when detected early.’’ The Committee concurs with these findings and acknowledges that the medical breakthroughs which have been developed in the twelve years

since the issuance of this report make early intervention even more

important. This authorization reflects the Committee’s intent to increase the coordination between HIV prevention and HIV care and

treatment services in all CARE Act programs. The Committee expects such activities will be of particular importance when focusing

on underserved populations, and of particular value in bringing

into and retain in care those individuals who are knowledgeable of

their status but are not receiving services.

HIV Reporting. According to CDC, in June 1999 there were an

estimated 287,946 Americans living with AIDS. Currently, CDC is

not able to determine how many Americans were living with HIV,

because only 29 states report HIV cases. CDC expects all states to

be reporting newly diagnosed HIV cases by 2003 and than an additional 1 to 3 years may be needed to get all HIV cases entered into

such new reporting systems. It is difficult for regions without reliable HIV surveillance to adequately address the needs or understand the scope of the epidemic.

The identification of HIV reporting as a serious public health

concern was identified by the first Presidential Commission on

HIV, appointed by President Reagan, which issued the ‘‘Report of

the Presidential Commission on the Human Immunodeficiency

Virus Epidemic’’ on June 24, 1988. According to that report:

The term ‘‘AIDS’’ is obsolete. ‘‘HIV infection’’ more correctly defines the problem. The medical, public health, political, and community leadership must focus on the full

course of HIV infection rather than concentrating on later

stages of the disease (ARC and AIDS). Continual focus on

AIDS rather than the entire spectrum of HIV disease has

left our nation unable to deal adequately with the epidemic. Federal and state data collection efforts must now

be focused on early HIV reports, while still collecting data

on symptomatic disease.

30

Eleven and a half years later, the CDC has implemented proposals consistent with proposals made by President Reagan’s Commission on the Human Immunodeficiency Virus Epidemic.

To address the challenge of insufficient value being derived from

AIDS data alone, CDC joined the Council of State and Territorial

Epidemiologists (CSTE) to recommend in December 1999 that all

states and territories include name surveillance for HIV infection

as an extension of their AIDS surveillance activities. On May 11,

2000,

Surgeon General Satcher testified before the Subcommittee on

Health and Environment that he agreed with the CDC and CSTE

recommendation. In light of the consensus that has finally

emerged, the Committee believes all jurisdictions should shift the

focus from AIDS to the full spectrum of HIV infection for improved

prevention and care. Federal funding as well should be based upon

the full extent of the disease rather than only on the late stages

defined as AIDS. This will ensure more equitable funding and more

timely and appropriate responses.

The consequences and human toll of dithering over HIV reporting over the last decade has been high, and not just in this country.

The Committee believes that other public health institutions

throughout the world have not yet adopted HIV reporting, and for

this reason the Committee strongly recommends that the CDC

should work in consultation with HRSA on all international HIV/

AIDS initiatives to avoid repeating mistakes made in the past. The

Committee is also concerned that, because public health institutions had no data to show the rate of growth of HIV cases among

various American cultural and ethnic communities, communities of

color are disproportionately affected and infected by the HIV epidemic.

HIV Case Classification. The Committee is aware of concerns

that the heterosexual and NIR categories as currently defined may

result in systematic underreporting of heterosexual cases of HIV,

which could be detrimental to addressing the prevention needs of

certain groups, particularly communities of color.

This classification system may have been satisfactory early in

the epidemic, but the changing dynamics of the HIV/AIDS epidemic

require a timely reassessment and refinement of current classification methods. The Committee applauds the CDC’s recognition of

State efforts to accomplish these goals, including Virginia’s efforts

to identify NIR cases with multiple sex partners. The CDC has indicated that it is also currently reassessing HIV/AIDS case classification methods to ensure the most adequate understanding of the

disease and its modes of transmission and to properly allocate and

target resources to those groups that are increasingly at risk of infection, such as African American females.

Based on this understanding, the Committee urges the Secretary

to commit to an agenda of coordinated actions with the States and

patient advocates, including the development and validation of rigorous sampling techniques, the promulgation of formal guidance to

the States, the provision of technical assistance to State and local

health authorities, and the expansion of the CDC’s current pilot

projects with interested States. Finally, the Committee applauds

the CDC’s commitment to hold a public meeting to obtain expert

31

opinion on this issue, and its current efforts to consult with the

Committee prior to the meeting regarding its attendance.

Demographics and Needs of Populations with HIV Disease. The

comprehensive service delivery plan is an effective way to demonstrate the organization and delivery of CARE Act services based

upon the planning, priority setting, and funding allocation processes conducted by the planning council. The intent of the legislation is also to have the additional factors reflected in the plan.

Those factors include disparities in access to medical and healthrelated support services by specific subpopulations; the needs of

persons with HIV not in care; capacity development needs; and

quality of HIV primary care and health-related supportive services.

Both the planning process and the resulting plan should include

the participation of, and address the needs of, populations and subpopulations living with HIV and AIDS.

The Committee requires that Planning Councils determine the

size, demographics and needs of the population with HIV disease.

The Committee recognizes that adequate and reliable data on HIV

prevalence may not be uniformly available in all eligible areas on

the date of enactment. Therefore, priorities for the allocation of

funds and the comprehensive plan should reflect HIV prevalence to

the extent that data are reasonably available. The Committee also

notes that ‘‘HIV disease’’ under the CARE Act encompasses both

persons living with AIDS as well as persons diagnosed as HIV positive who have not developed AIDS.

The reauthorization bill reflects the Committee position that priority setting and funding allocation decisions should be based on

the size and demographic characteristics of the populations with

HIV disease in the eligible area. Planning, priority setting, and

funding allocation processes must take into account shifts in the

local HIV/AIDS epidemic, existing health HIV-related disparities,

and resulting negative health outcomes.

The Committee intends Planning Councils to develop a strategy

to identify individuals with HIV disease who are not receiving services and to inform and enable such individuals to receive services

under Title I. The Committee wants CARE Act providers to work

actively to bring into and retain in care those individuals who are

unaware of their HIV status and those who are knowledgeable of

their status but are not receiving services. As part of this process,

the Committee believes strongly in the importance of Planning

Councils focusing on eliminating disparities in access and services

among affected subpopulations and historically underserved communities. The Committee recognizes that the availability or lack of

HIV prevalence data in particular EMAs will be reflected in the

scope, goals, timetable and allocation of funds for implementation

of the strategy.

The Committee also intends Planning Councils to develop a

strategy to coordinate the provision of Title I services with HIV

prevention services and substance abuse prevention and treatment

services. The Committee has amended numerous aspects of CARE

Act programs to enhance the coordination between HIV prevention

and HIV care and treatment services. The Committee further requests that the Secretary work with title I grant recipients and

providers to establish epidemiologic measures and tools for use by

32

EMAs in identifying the number of individuals with HIV infection,

especially those who are not in care.

The Committee expects that the development of such measures

will refine and expand the ability of EMAs and Planning Councils

to identify and provide services to individuals with HIV disease

who are not receiving services. The efforts on the part of EMAs and

Planning Councils to accomplish these important tasks, however,

should not be delayed until this process is complete. Instead, the

Committee expects EMAs and Planning Councils to establish and

implement strategies responsive to these urgent needs before the

development of nationally uniform measures, to the extent that is

practicable and to which necessary prevalence data is reasonably

available.

Early Intervention Services. The Committee authorizes early

intervention services as eligible services under certain circumstances in Titles I and II. The Committee intends to allow

grantees to provide certain early intervention services, such as HIV

counseling, testing, and referral services, to individuals at high risk

for HIV infection in accordance with statewide planning and regional consortia planning activities. Additionally, the Committee

intends that the types of organizations that may provide early

intervention services are the same as those that provide other HIVrelated services through Parts B or C of the Act, or are points of

access into the health care system for individuals at high risk for

HIV, as specified by States under guidance from HRSA’s Bureau

of HIV/AIDS.

The Committee recognizes that these organizations may include

traditional community based organizations (CBOs) that act as

points of entry and/or referral agencies into the health care system,

especially for traditionally underserved and minority populations.

This provision is solely for the purpose of expanding the scope of

primary care services to include HIV testing, counseling, and referral. The Committee recognizes the importance of early intervention

services in increasing access to medical services through established relations with a broad network of health care entry points

and HIV medical providers that serve as critical entry points for

medical services for uninsured, and underinsured, low-income and

rural communities. The Committee specifically intends that funds

not be used to supplant other funds available to States for the provision of early intervention services and that these funds are utilized only when existing Federal, State or local funds are inadequate to provide these services. Further, the Committee intends

that such services need to be provided according to guidelines established by the CDC and according to the laws and administrative

regulations of State and local governments. The Committee expects

that the Secretary, working with grantees and the public health

community, will provide guidance to establish the appropriate parameters for the use of CARE Act funds for these purposes and to

coordinate these activities with existing early intervention services.

The Committee recognizes that other funding sources may exist for

these services and expects all grantees to seek out and use these

funds to enhance medical care to the extent they are reasonably

available.

The Committee finds that all counseling for HIV-infected individuals should emphasize that it is the duty of infected individuals to

33

disclose their infected status to their sexual partners and others

who are they potentially may place at risk of infection. The Committee recognizes that proper counseling better enables individuals

living with HIV to make such disclosures. The Committee intends

for entities providing care under this legislation will provide such

counseling and emphasize that it is the continuing duty of the infected individuals to avoid any behaviors that will expose others to

HIV.

The Committee heard testimony in 1998 from an HIV infected

man who became infected because his partner hid his HIV status

and did so after counseling from Federally supported organizations

which did not advise him to disclose. The Committee believes that

this policy all those who are infected should be provided proper advice to disclose and provided the counseling to do so. Recent studies

have found that the continuing epidemic in the United States is

being driven by infected individuals who do not disclose their status and continue to engage in risky behaviors. The Committee believes that existing prevention policies have failed to adequately

address such behavior and have enabled them to continue. This

provision will provide better secondary prevention and protect the

infected from other health complications including dual HIV infection.

Rapid HIV Test. The Committee also seeks to expand and coordinate efforts at the NIH and FDA to develop rapid HIV tests. Accurate and affordable rapid HIV tests have many potentially important applications, one of which would be to help diagnose pregnant

women whose HIV status is not known late in pregnancy or at the

time of labor. The purpose of this initiative is to help increase opportunities for individuals, including pregnant women, to learn

their HIV status. The Committee recognizes that labor is not an

ideal time to obtain consent for testing or to discuss the implications of a positive test result. It is not the intent of this Committee

to diminish the right of patients to make an informed decision to

be tested. In establishing or updating relevant guidelines, CDC

should address how to ensure that the meaningful decision making

ability of patients is preserved. These guidelines should recognize

that states have varying laws and policies related to the communication of test results. The Committee encourages the FDA to facilitate CDC’s ability to use rapid HIV tests as soon as possible,

consistent with the FDA’s approval process.

Partner Notification. The results of various regional studies confirm that partner notification is a useful and effective intervention

and prevention tool. Infected individuals are less likely to notify

partners themselves, but will cooperate with programs conducted

by public health professionals. Studies and surveys have also concluded that partners notified about potential exposure to HIV support notification programs.

The Presidential Commission on HIV stated, ‘‘public health authorities across the United States must begin immediately to institute confidential partner notification, the system by which intimate

contacts of the person carrying sexually transmitted diseases, including HIV, are warned of their exposure.’’

Partner notification has proven to be highly effective. Up to 90

percent of those who test positive cooperate voluntarily with notification. Further, even higher proportions of those partners conVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00033 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
34

tacted—usually 90% or more—voluntarily obtain an HIV test. But

only 10 percent or less of people who have recently tested HIV-positive manage, by themselves, to notify their partners.

Partner notification is especially important for women because

many HIV-infected women do not engage in high risk behaviors but

were infected by a partner who does. Recent studies indicate that

AIDS develops more quickly in women who would therefore benefit

from being alerted to their condition as early as possible. Partner

notification has been credited, in part, by the public health community for the fact that syphilis cases in the U.S. have fallen to the

lowest levels in history.

The Committee heard testimony from the State of Florida, which

recently enacted a partner notification program, that such ‘‘activities are effective interventions for reaching individuals at high risk

of HIV infection and are unaware of their risk.’’ States have been

successful in reducing the number of new HIV infections—contrary

to national trends—in large part to effective partner notification

programs.

The legislation authorizes $30 million for states to enact such

policies, but does not require that they do so as a condition of eligibility for Title II funding. States with systems that are approved

by the CDC will receive preference for these grants. No State that

does not meet the CDC surveillance recommendations will be eligible for these funds after 2004.

Vulnerable Populations. The Committee is concerned that not all

Americans receive the same quality of treatment under the CARE

Act. As the GAO found in its report entitled ‘‘HIV/AIDS: Use of

Ryan White CARE Act and Other Assistance Grant Funds’’:

Women also did not fare as well as men on most of the

measures. Finally, exposure category was a significant factor; those who had acquired their infection by injecting

drugs or through heterosexual sex had less favorable patterns of care than did men who had sex with men [MSM].

Therefore, the Committee strongly encourages the Office of HIV/

AIDS Policy and the Office on Women’s Health (OWH) to provide

a report to Congress on all activities conducted by the US Department of Health and Human Services that impact women who are

infected and affected by HIV/AIDS. The report shall include an

evaluation by the OWH of the scope and effectiveness of these activities. It will also identify gaps in prevention and care services

and in research involving or targeted towards women living with

HIV/AIDS. The HHS Secretary shall direct the appropriate agencies within the Department to collaborate with the OWH on such

a report.

Priority for Women, Infants, Children and Youth. The Committee

has expanded the existing priority on services for women, infants

and children to also include youth. The Committee intends the

term ‘‘youth’’ to include persons between the ages of 13 and 24, and

the term ‘‘children’’ to include those under the age of 13, including

infants.

The Committee emphasizes that the minimum amount established by H.R. 4807 is in no way to be construed as a maximum

on how much a planning council may spend on these populations.

The Committee also recognizes that these priority populations

35

often comprise a greater proportion of HIV cases rather than AIDS

cases in a local area. If data on HIV, rather than the endstage of

AIDS, are available, planning councils should take this into account when allocating resources.

The Committee recognizes that, according to the CDC, young

people ages 24 and under account for at least half of new HIV infections. The Committee urges planning councils to assure that

more is done to provide appropriate services to youth, including

prevention, in coordination with Title IV grantees operating in the

area.

Perinatal Transmission. Perinatal transmission of HIV is the

leading cause of pediatric cases AIDS, and the Committee recognizes the importance of life-saving newborn screening programs.

According to the 1998 Institute of Medicine report ‘‘Reducing the

Odds: Public Health Screening Programs’’, these programs have a

long pedigree in the public health profession:

The first parental screening program mandated by law

was for syphilis in the 1930s and 1940s. In early 1960s,

many states mandated newborn screening for PKU, a condition that can lead to mental retardation without dietary

interventions, and other inborn errors of metabolism.

Screening for other inborn errors of metabolism (congenital

hypothyroidism, galactosemia, homocystinuria,

histidenemia, maple syrup urine disease, and tyrosinemia)

followed in the 1970s. In the early 1970s, many states initiated mandatory screening for sickle cell disease, a disease that had limited treatment options, in a variety of

populations. Later in the same decade, maternal serum

alpha-fetoprotein tests were introduced, on a voluntary

basis, to help detect neural tube defects. Today, specific

tests mandated or recommended as standards of practice

vary substantially across state lines. Mandatory prenatal

and newborn testing for substance abuse is increasingly

common.

Despite improved progress in developing effective strategies to

reduce perinatal HIV transmission, the CDC estimates that nearly

7,000 HIV-infected women give birth in the United States each

year and as many as 400 babies continue to be born with HIV infection each year. Breastfeeding by HIV-infected mothers poses additional significant risk of infection to babies.

Even if there were no effective therapies for perinatal HIV transmission, routine testing still would benefit the public health. As the

1998 IOM report pointed out,

In 1936, Thomas Parran, the U.S. Surgeon General, established a program for controlling syphilis that included

mandatory prenatal blood tests * * *. Although these laws

were passed before the introduction of antibiotic treatment, they resulted in rapid decline in congenital transmission through case finding * * * contact tracing, and

the difficult and less effective therapies available at the

time. Perhaps the most important aspect of these screening programs was that by making testing routine, they

overcame the resistance of physicians to risk offending patients by suggesting a test for syphilis.

36

Fortunately, medical advances have made it possible to nearly

eliminate perinatal HIV transmission. In 1994, research studies

demonstrated that the administration of antiretroviral medication

during pregnancy, during labor, and to the infant immediately following birth can significantly reduce the transmission of HIV from

an infected mother to her baby. From 1994 to 1999, as a result of

these interventions, pediatric AIDS cases resulting from perinatal

HIV transmission declined by nearly 80 percent. Subsequent studies have indicated that cesarean sections further reduce the risk of

transmission. Studies also indicate that, even if treatment begins

shortly after birth, antiretroviral therapy can substantially reduce

the chance that an HIV-exposed child will become infected.

Due to the availability of interventions to reduce perinatal HIV

transmission and to improve the health of HIV-infected women and

their children, it is important to increase the number of pregnant

women who receive prenatal care and are tested for HIV. In 1995,

the House approved a measure requiring universal HIV testing of

all newborns. The American Medical Association recommends HIV

testing for all pregnant women and newborns with counseling and

recommendations for appropriate treatment. The IOM has recommended the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal

care. Regrettably, according to the IOM, 15 percent of HIV-infected

pregnant women receive no prenatal care at all.

The routine offering of HIV testing to pregnant women should be

a standard of care. Sufficient information must be provided to a

pregnant woman so she can make an informed decision to be tested. Studies show that the vast majority of pregnant women will accept an HIV test if it is offered to them. In addition, testing

newborns whose mothers’ HIV status is unknown helps to ensure

that children at risk for HIV are identified and provided treatment.

The offering of HIV testing to pregnant women and to newborns

whose mothers’ HIV status is unknown, combined with appropriate

counseling and treatment, can significantly reduce perinatal HIV

transmission, improve access to medical care for HIV-infected

women and children, and provide opportunities to further reduce

HIV transmission among adults.

For the reasons cited above, the Committee finds the following:

(1) universal, routine offering of HIV testing to pregnant women

should be a standard of care; (2) HIV testing of newborns whose

mothers’ HIV status is unknown a standard of care; and (3) relevant medical organizations, public and private payers of health insurance, and public health officials should issue or update relevant

HIV counseling, testing and treatment guidelines accordingly.

The Committee also recognizes the need for additional resources

to further reduce perinatal HIV transmission. The legislation authorizes an additional $20 million for activities to reduce perinatal

transmission, including outreach, education, testing and treatment

for pregnant women and their newborns.

The current statute requires, as a condition of funding, that

States have regulations or measures to adopt CDC guidelines concerning HIV counseling and testing for pregnant women and

newborns. Women who initially refuse testing should be encouraged to reconsider at later points in their pregnancy. When appropriate, pregnant women who accept testing when it is initially ofVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00036 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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fered and test negative should be encouraged to get tested again

later in pregnancy.

Additionally, consistent with State laws and regulations, sufficient information should be provided to all pregnant women so they

can make an informed decision to be tested for HIV. Adequate

training and education should be provided to prenatal care providers on the risks of perinatal transmission, and the importance

of offering HIV tests to all pregnant women, the benefits of interventions, and the availability of referral sites for women who test

positive should be emphasized.

The Committee also believes that it is also important that appropriate post-test counseling, referrals, and linkages to care for HIVpositive women and their children be provided, and that women are

not counseled to terminate their pregnancies on the basis of HIV

status. States should also have to show that they are taking steps

to increase the proportion of women who receive prenatal care, including targeted outreach and education efforts in areas with highest numbers of women who get no or inadequate prenatal care. Reforms to State insurance laws should require that, if health insurance is in effect for an individual, the insurer involved may not

(without the consent of the individual) discontinue the insurance,

or alter the terms of the insurance, solely on the basis that an individual has been tested for HIV or is infected with HIV.

The Committee has reserved a portion of the additional funding

for States that conduct HIV testing of all newborns, or newborns

whose mothers’ HIV status is unknown. If newborn testing is conducted, in order to maximize the opportunity for reduction of

perinatal transmission after birth, the Committee urges states to

assure that test results are provided within 48 hours. The Committee recognizes that HIV test results for the newborn will generally also reveal the HIV status of the mother. Therefore, if a newborn tests positive for HIV, it is essential for the mother to be informed of the test results and provided care in a sensitive manner

that is consistent not only with CDC guidelines, but also with appropriate measures to protect the confidentiality of both mother

and child.

The Committee encourages all states, including those that do not

apply for this additional funding, to take these steps and other activities as necessary to reduce perinatal HIV transmission. States

are encouraged to coordinate their activities with those of Title IV

grantees and other entities that provide services related to the reduction of perinatal HIV transmission. Where appropriate, states

are encouraged to provide a portion of grants under this section to

Title IV grantees operating in the State.

To assure that there are no financial barriers to the offering of

HIV testing to all pregnant women or to providing treatment to reduce perinatal HIV transmission and improve the health of HIVpositive women and children, the Committee encourages all payers

of health insurance, both public and private, to assure that HIV

testing and treatment during pregnancy and for the mother and

child are covered benefits.

The Committee requires that States report to Congress on the

progress toward meeting the recommendations of the IOM. Those

who have not made progress toward meeting such recommendations must, as a condition of receiving funding, cooperate with the

38

CDC and submit a report to the Secretary on progress identifying

and overcoming barriers to eliminating perinatal HIV transmission.

The Committee does not intend that this bill detrimentally affect

religious practices or religious freedom. However, nothing in this

bill is designed to preempt existing or prohibit new State religious

accommodation laws that allow those with religious objections to

decline to have their newborn infants tested for HIV disease if such

exemptions exist under state law for other reportable diseases. Further, religious accommodation laws enacted by recipient States

shall have no impact whatsoever on the level of federal funding received by the recipient State.

The Committee heard testimony from Mr. Tom Liberti, Chief,

Bureau of HIV/AIDS, Florida Department of Health, who detailed

how the enactment of a successful HIV reporting system enabled

the state to better address the epidemic, particularly within the African-American and Hispanic communities. The availability of such

a system will better ensure that all communities affected are recognized and are receiving appropriate care and medical access, thereby reducing disparities and allowing for the equitable allocation of

funds.

Minority AIDS Initiative. While the Ryan White CARE Act, in

general, has had significant success in addressing the needs of individuals and communities affected by the disease, ethnic and racial

minority communities continue to experience disparities in health

outcomes in terms of HIV and AIDS. The legislation includes several provisions that intend to refocus and enhance representation,

planning, prioritization, and allocation of CARE Act resources to

address disparities in health outcomes and the needs of historically

underserved and vulnerable communities.

According to the written testimony of Loretta Davis-Satterla, Director, Division of HIV/AIDS–STD with the Michigan Department

of Community Health submitted for the Subcommittee on Health

and Environment hearing on May 11, 2000:

In Michigan, confidential HIV reporting has been required by statute since 1989. Confidential HIV reporting

has greatly enhanced Michigan’s ability to rapidly and effectively respond to the dynamics of this epidemic * * * In

contrast to AIDS case surveillance, HIV case surveillance

provides data to better characterize populations in which

HIV infection has been newly diagnosed, including persons

with evidence of recent HIV infection. Compared with persons living with AIDS, those reported living with HIV infection in Michigan are more likely to be women (18% for

AIDS vs 26% for HIV) and African Americans (55% for

AIDS and 62% for HIV). Approximately 1% of AIDS cases

occurred in both persons aged 13–19 years and 20–24

years. In comparison, 4% of HIV cases occurred in persons

aged 13–19 years and 13% of HIV cases occurred in persons 20–24 years. Thus, AIDS case surveillance alone does

not accurately reflect the extent of the HIV epidemic

among African Americans, women, adolescents and young

adults.

39

In addition, the Committee affirms the intent of the Minority

AIDS Initiative (MAI) in addressing the unique needs of ethnic and

racial minority communities. The initiative is intended to complement and supplement, not supplant, the efforts of the Ryan

White CARE Act and other national AIDS programs. The MAI was

instituted in response to the overwhelming and disproportionate

impact of the HIV epidemic on ethnic and racial minority communities.

The MAI is intended to address the needs of Americans in highly

impacted communities by enhancing outreach and education,

strengthening technical assistance, and supporting capacity building of ethnic and racial minority community based organizations

and institutions and providers to deliver culturally competent and

appropriate HIV-related prevention, health care, and support services. The initiative also seeks to expand or fund new research initiatives to develop and evaluate culturally competent intervention

strategies directed towards reducing and ultimately eliminating the

HIV-related health disparities experienced by ethnic and racial minority populations. In this regard, the MAI may prove to be a significant component of an overall strategy for addressing the disease. The Committee encourages the Department of Health and

Human Services to include the MAI in its efforts to achieve an integrated and coordinated system of HIV/AIDS care and treatment.

With respect to entities that currently receive or have received

planning grants through special initiatives such as the MAI, the

Committee intends that these entities will be still be eligible for

such grants under Part C if they meet the appropriate funding criteria.

MAI funding is intended to be targeted to ethnic and racial minority-governed and staffed organizations and where no such organization exist, to institutions that have a history of providing culturally competent services to the communities and populations they

are targeting. The funding is intended to build capacity and infrastructure within these communities, and fill gaps in critically needed HIV and AIDS services. This includes providing primary HIV

prevention, increasing access to HIV and related health and support services, and ensuring continuity of care for ethnic and racial

minority populations and sub-populations including minority

women, youth, MSMs, substance abusers, homeless, incarcerated

and recently-released individuals.

Incarcerated Populations. The Committee recognizes that HIV

public health interventions implemented in correctional settings

have great potential to have a significant impact on the epidemic.

The success of in-prison interventions requires continuation of medical treatment and behavior modification following release. Post-release failure of inmates to adhere to HIV medical regimens may

pose public health dangers by fostering development and transmission of drug-resistant HIV variants. Also, because the vast majority of inmates will be released to their communities, prison, jail,

and similar restricted institutions intervention is vital to reduce

HIV transmission to the general public. Therefore, the Committee

believes that improved discharge planning and continuity of care

between correctional facilities and communities are needed to increase the likelihood that HIV-positive releasees will obtain the

care they need and take precautions to avoid spreading the disease.

40

Effective pre-release programs can also help inmates make positive

changes in their lives to avoid returning to crime, with the resulting reduced recidivism rates yielding significant benefits to society.

The Committee therefore urges the Secretary to give favorable consideration to grants under the Ryan White CARE Act for programs

that provide linkages with correctional discharge planning and

other transitional services needed to help HIV-positive inmates

move successfully from correctional institutions to their communities. These transitional services, which may be needed up to six

months prior to release, may include, but are not limited to, clinical

referrals, psychosocial services, enrollment in medical care funding

programs, a short-term supply of medications upon release, HIV

pre-release identification efforts, HIV prevention education, HIV

related counseling, coordination and referral, and linkages for substance abuse treatment, and HIV related case management services and linkages to CARE Act programs in their communities.

In addition to prisons and jails, other residential institutions,

such as substance abuse treatment facilities and mental health institutions, also have a high concentration of persons at high risk

of HIV infection and pose similar intervention opportunities and

challenges. The Committee thus urges the Secretary to give favorable consideration to grants under the Ryan White CARE Act for

programs that provide discharge planning and other transitional

services, including the types of services enumerated above, which

are needed to help HIV-positive institutional residents move successfully from institutions to their communities.

Quality Assurance. The Committee recognizes the importance of

having CARE Act grantees ensure that quality services are provided to people living with HIV and that the quality management

activities are conducted on an ongoing basis. Quality management

activities should: assess the extent to which HIV health services

provided under this grant are consistent with Public Health Service

guidelines for the treatment of HIV and the treatment and prevention of related opportunistic infections and, as applicable, lead to

the development of strategies to ensure that such services are consistent with the guidelines and that social support services are provided in a manner as to gain or enhance the benefits of health care

services.

The Committee expects the Secretary to provide States with

guidance and technical assistance for establishing quality management programs, including disseminating such models that have

been developed by States and are already being utilized by Title II

programs and in clinical practice environments. The Committee

hopes that States will communicate and coordinate CARE Act requirements with other payers to the extent possible to ensure consistency in quality management activities. The Committee expects

that most States have quality management systems in place already and that they utilize mechanisms such as peer chart reviews

or patient prescription pattern monitoring. The Committee places

responsibility on the Secretary to ensure that PHS guidelines, as

well as population characteristics and trends in the use of HIV

services, are communicated to all CARE Act grantees and subgrantees. This information, the Committee believes, will assist

grantees in ensuring the highest quality of HIV care among CARE

Act providers.

41

The Committee intends that the Secretary provide clarification

and guidance regarding the distinction between use of CARE Act

funds for such program expenditures that are covered as either

planning and evaluation and funds for program support costs. Program support costs are described as any expenditure related to the

provision of delivering or receiving health services supported by

CARE Act funds. As applied to the clinical quality programs, these

costs include, but are not limited to, activities such as chart review,

peer-to-peer review activities, data collection to measure health indicators or outcomes, or other types of activities related to the development or implementation of a clinical quality improvement program. Planning and evaluation costs are related to the collection

and analysis of system and process indicators for purposes of determining the impact and effectiveness of funded health-related support services in providing access to and support of individuals and

communities within the health delivery system.

HIV Consortia. The Committee intends that States continue to

work with local Consortia to ensure that they identify potential disparities in access to HIV care services at the local level, with a special emphasis on those experiencing disparities in access to care,

historically underserved populations, and HIV infected persons not

in care. However, the Committee does not intend that States and/

or Consortia be mandated to consult with all entities referenced as

part of the planning process under Part A. The Committee intends

that States and Consortia will continue to work with the appropriate entities in their jurisdictions to assess and plan services at

the local level. Reference to entities included in the Title I planning

process is intended to provide guidance to the States that such entities are important constituencies which the States should endeavor to include in their planning processes. The Committee intends

that the States require local Consortia to document their efforts to

identify and address access disparities at the local level, as appropriate.

Title II Comprehensive Plan. The comprehensive service delivery

plan is an effective way to demonstrate the organization and delivery of CARE Act services, based upon the planning, priority setting, and funding allocations processes conducted by the State. The

Committee intends that States may demonstrate compliance with

the new requirement of an enhanced process of public participation

by indicating in their applications existing mechanisms for consumer and community input, and describing how such mechanisms

influence the use and distribution of funds and the number of persons not in care and unmet needs of persons not receiving health

services. The Committee intends States to develop a strategy to

identify individuals with HIV disease who are not receiving services and to inform and enable such individuals to receive services

under Title II. The Committee wants CARE Act providers to work

actively to bring into and retain in care those individuals who are

unaware of their HIV status and those who are knowledgeable of

their status but are not receiving services. As part of this process,

the Committee believes strongly in the importance of the States focusing on eliminating disparities in access and services among affected subpopulations and historically underserved communities.

The Committee recognizes that the availability or lack of HIV prevalence data in particular States will be reflected in the scope, goals,

42

timetable and allocation of funds for implementation of the strategy.

The Committee also intends States to develop a strategy to coordinate the provision of Title II services with HIV prevention services and substance abuse prevention and treatment services. The

Committee has amended numerous aspects of CARE Act programs

to enhance the coordination between HIV prevention and HIV care

and treatment services.

The Committee intends that additional factors be reflected in the

plan such as disparities in access to medical and health-related

support services by subpopulations. Upon the development of measures by the Secretary and Title II grantees, as described above, the

needs of persons with HIV not in care should be considered in the

comprehensive plan. Both the planning process and the resulting

plan should continue to include the participation of, and address

the needs of, populations and subpopulations living with HIV and

AIDS. The specific needs of populations or subgroups, such as

women, people of color, persons who are underinsured or uninsured, youth, homeless persons, persons living in rural areas, or

persons with substance abuse or other co-occurring conditions within the State need to be specifically addressed. States should continue to consider the availability of services through other public

and private health care payers and providers including Medicaid,

the State Children’s Health Insurance Program (SCHIP) and other

public and private sources of health care reimbursement. States

should ensure that there are strong coordinating mechanisms between Ryan White and the State Medicaid programs to assure optimal health care for persons living with HIV disease. States should

continue to collaborate with other health care and social service

providers and payers through the Statewide Coordinated Statement of Need (SCSN) process. The Committee does not intend to

mandate that States devote specific portions of their Title II grant

funds to specific activities. The Committee recognizes the need for

flexibility for States in the administration of Title II programs in

order to ensure that local needs are addressed.

ADAP. The legislation strengthens the ADAP program to assist

States that are struggling to provide medications to all of their

needy clients. The Committee has also sought to strengthen the

ability of local communities, States, and service organizations to

reach those communities and populations that have been historically most underserved, as well as those that are experiencing

rapid increases in HIV infection and AIDS case counts but that

have not been brought into the care system developed under Ryan

White. The purpose of these changes is to ensure a strong system

of health care delivery and access to therapies commensurate with

evolving needs.

This section has been amended to permit States to utilize funds

under this section to purchase and maintain health insurance on

behalf of individuals with HIV disease whose coverage provides a

full range of HIV therapeutics and primary care services. The Committee recognizes the cost-effectiveness and potential cost-savings

of such a mechanism in the provision of treatments and the fact

that several States have already fully integrated such mechanisms

into their treatment provision systems.

43

Grants for Coordinated Services and Access to Research for

Women, Infants, Children and Youth. The Committee does not intend to require Title IV applicants to file separate reports to the

Secretary to demonstrate linkages to research and how access to

such research is offered to patients. Instead, such reporting may be

completed as part of the existing grantee reporting process. The report on the distribution and availability of ongoing and appropriate

HIV/AIDS-related research projects shall not be interpreted as requiring the Secretary to recommend the redistribution of funds for

such research projects or to act on redistributing these funds based

on the report’s findings.

Early Intervention Services. The Committee expects that EMAs

will provide services to American Indian and Native American peoples. Native Americans and American Indians are eligible for Ryan

White services through State and Federal citizenship. The Committee supports better co-ordination of Ryan White services for Native Americans and American Indians in order that they may realize the full potential of HIV/AIDS-related primary care and support

services provided through CARE Act funding.

The Committee also recognizes that the US Department of Veterans Affairs is the largest single direct provider of HIV care and

services in the US. Over 18,000 veterans received HIV care at VA

facilities in 1999. Veterans with HIV infection are eligible to participate in Ryan White Title I programs when they meet eligibility

requirements set by Title I Planning Councils, and EMA plans for

the delivery of services must account for the availability of VA

services. VA facilities are eligible providers of HIV health and support services where appropriate. The Committee expects that

HRSA’s Bureau of HIV/AIDS shall encourage Ryan White grantees

to develop collaborations between providers and VA facilities to optimize coordination and access to care to all persons in Title I

EMAs.

The Committee understands that the Secretary has convened a

Public Health Service Working Group on HIV Treatment Information Dissemination, which has produced recommendations and a

strategy for the dissemination of HIV treatment information to

health care providers and patients. Recognizing the importance of

such a strategy, the Committee intends that the Secretary issue

and begin implementation of the strategy to improve the quality of

care received by people living with HIV/AIDS.

Administrative Simplification. The Committee is aware of the

enormous administrative burden that the current grant application

process places on States and recipients of grants under Part A. The

Committee is concerned that the current application process may

divert critical resources from the provision of care. Therefore, the

Committee directs the Secretary to consult with States and recipients of grants under Part A regarding the coordinated disbursement of funds under Part A with the disbursement of funds under

Part B, the implementation of a biennial application process under

Parts A and B, and the overall simplification and streamlining of

the grant application for funds under Parts A and B. The Committee expects that the Secretary will undertake this consultation

with States and entities receiving funds under Part A in an expeditious manner and will work with these States and entities to implement agreed upon strategies as soon as possible.

44

Audits and Consumer Participation. The Committee intends that

to the maximum extent possible the funds made available through

this legislation are intended for the actual medical and support

services needs of the infected population, and not simply ‘‘quality

of life’’ issues. According to a November 13, 1997 New York Times

story, some services that have been offered using Federal funds included ‘‘free dog walking.’’ Any funds misallocated through frivolity,

waste or outright fraud deny someone else living with HIV much

needed care.

At the July 11, 2000 hearing the Subcommittee heard testimony

from Jose Fernando Colon, Coordinator for Pacientes de SIDA Pro

Politica Sana (AIDS Patients for Sane Policies) in San Juan, Puerto

Rico. Mr. Colon detailed for the Committee how millions of dollars

of money intended for AIDS services was diverted for personal and

political purposes, resulting in numerous Federal Court convictions

in Puerto Rico. He testified that in 1993 the Department of Health

and Human Services was made aware of possible misconduct, but

that no investigation was ever conducted.

The GAO reported to the Congress on October 18, 1999 that they

had identified two other cases in which fraud and abuse have occurred in regard to CARE Act funds. However, the GAO did not

find such fraud and abuse to be either systemic or widespread

among grantees or in CARE Act programs. As HRSA Administrator

Claude Fox, MD testified to the Subcommittee:

The GAO has looked at it and said there is not a widespread problem. We agree with the provisions in this bill.

We want to do everything that we can do within reason to

make sure that these funds are well spent. But we do not

believe that it is a widespread problem.

H.R. 4807 includes important provisions to prevent and detect

fraud with CARE Act funds.

The legislation also contains important provisions which ensure

that not less than 33% of Title I HIV Health Services Planning

Councils are composed of individuals who are receiving HIV-related

services.

The Committee emphasizes that its intent is to ensure that patients and consumers of Title I services constitute a substantial

proportion of Planning Council memberships. The prohibition of officers, employees and consultants is not intended to impede the

participation of qualified, motivated volunteers with Title I grantees from serving on Planning Councils where they do not maintain

significant financial relationships with such grantees. In contrast

to such significant financial relationships, volunteers may be reimbursed reasonable incidental costs, including for training and

transportation, which help to facilitate their important contribution

to the Planning Councils.

The Committee intends that Planning Councils ensure its members are knowledgeable about their duties, the functions of the

Councils, and the Councils’ role in the organization and delivery of

HIV/AIDS health and support services. The provision of training

guidance and materials to the Councils by HRSA’s Bureau of HIV/

AIDS will go far to ensure that Council members, particularly patients and consumers of HIV/AIDS services, can serve effectively

45

and improve the allocation of resources and the planning and implementation of Title I services.

The Committee also expects Planning Councils to provide assistance, such as transportation and childcare, to facilitate the participation of consumers, particularly those from affected subpopulations and historically underserved communities.

Further, the bill ensures that grants will be available for training members of these planning councils, and that planning council

meetings will be open to the public. Mr. Colon stated that these

types of reforms will lead to increased accountability, and the Committee agrees with this assessment.

Further, for the first time, the Committee intends that the Secretary may reduce grants to States or political subdivisions of

States which fail to prepare and submit audits to the Secretary.

From these audits, the Secretary must annually randomly review

samples of the audits, ensuring that CARE Act funds are being appropriately expended.

HEARINGS

The Subcommittee on Health and Environment held a hearing on

July 11, 2000. The Subcommittee received testimony from: Claude

Earl Fox, M.D., M.P.H., Administrator, Health Resources and Services Administration, accompanied by Joseph O’Neil, M.D., M.P.H.,

Associate Administrator, Bureau of HIV/AIDS, Health Resources

and Services Administration; Ms. Janet Heinrich, Associate Director, US General Accounting Office, accompanied by Mr. Jerry

Fastrup, Assistant Director, US General Accounting Office; Ms.

Jeanne White, National Spokesperson, AIDS Action; Mr. Tom

Liberti, Chief, Bureau of HIV/AIDS, Florida Department of Health;

Guthrie S. Birkhead, M.D., M.P.H., Director, AIDS Institute, New

York State Department of Health; Mr. Joe Davy, Policy Advocate,

Columbus AIDS Task Force; Ms. Dorothy Mann, Board Member,

AIDS Alliance for Children, Youth & Families; Mr. Jose F. Colon,

Coordinator, Pacientes de SIDA Pro Politica Sana and; Mr. Eugene

Jackson, Deputy Executive Director for Policy, National Association

of People with AIDS.

COMMITTEE CONSIDERATION

On July 13, 2000, the Full Committee met in open markup session and ordered reported H.R. 4807, the Ryan White CARE Act

Amendments of 2000, as amended, by a voice vote.

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion

to report legislation and amendments thereto. There were no

record votes taken in connection with ordering H.R. 4807 reported.

A motion by Mr. Bliley to order H.R. 4807 reported to the House,

with an amendment, was agreed to by a voice vote.

The following amendments were agreed to by a voice vote:

An amendment by Mr. Coburn, No. 1, making various technical changes to the bill; and

An amendment by Mr. Strickland, No. 4, ordering States,

consortia, and supplemental grant applicants to seek comment

46

from an expanded body of stakeholders used by Title I EMA

cities when preparing their required plans.

The following amendments were withdrawn by unanimous consent:

An amendment by Ms. Eshoo, No. 2, replacing the ‘‘hold

harmless’’ provision in the bill with the Senate provision reducing the cut in Title I funds to 2% per year over 5 years; and

An amendment by Ms. DeGette, No. 3, giving States the option to cover pregnant women under the State Children’s

Health Insurance Program.

COMMITTEE OVERSIGHT FINDINGS

Pursuant to clause 3(c)(1) of rule XIII of the Rules of the House

of Representatives, the Committee held legislative and oversight

hearings and made findings that are reflected in this report.

COMMITTEE ON GOVERNMENT REFORM OVERSIGHT FINDINGS

Pursuant to clause 3(c)(4) of rule XIII of the Rules of the House

of Representatives, no oversight findings have been submitted to

the Committee by the Committee on Government Reform.

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

In compliance with clause 3(c)(2) of rule XIII of the Rules of the

House of Representatives, the Committee finds that H.R. 4807, the

Ryan White CARE Act Amendments of 2000, would result in no

new or increased budget authority, entitlement authority, or tax

expenditures or revenues.

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate prepared by

the Director of the Congressional Budget Office pursuant to section

402 of the Congressional Budget Act of 1974.

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House

of Representatives, the following is the cost estimate provided by

the Congressional Budget Office pursuant to section 402 of the

Congressional Budget Act of 1974:

U.S. CONGRESS,

CONGRESSIONAL BUDGET OFFICE,

Washington, DC, July 24, 2000.

Hon. TOM BLILEY, Chairman, Committee on Commerce,

House of Representatives, Washington, DC.

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 4807, the Ryan White

CARE Act Amendments of 2000.

47

If you wish further details on this estimate, we will be pleased

to provide them. The CBO staff contact is Julia Christensen.

Sincerely,

STEVEN LIEBERMAN

(For Dan L. Crippen, Director).

Enclosure.

H.R. 4807—Ryan White Care Act Amendments of 2000

Summary: H.R. 4807 would reauthorize programs in title XXVI

of the Public Health Services Act, which was created by the Ryan

White CARE Act (Public Law 101–381). Programs funded under

the Ryan White CARE Act address the needs of individuals living

with HIV disease. The bill would amend certain provisions under

that title to increase access to care and require that care to be consistent with the guidelines of the Public Health Service (PHS). The

bill also would create new grant programs to:

• Pay for health care services for individuals with HIV disease in states ineligible for emergency relief grants;

• Establish partner notification programs in the states, and

• Provide to states technical assistance with setting up data

surveillance and reporting systems related to HIV disease and

other funding for data collection efforts.

The Health Resources and Services Administration (HRSA)

under the Department of Health and Human Services (HHS) administers most of the Ryan White CARE Act programs; small portions are implemented through the Centers for Disease Control and

Prevention (CDC) and the National Institutes of Health (NIH). Assuming the appropriation of the necessary amounts, CBO estimates

that implementing H.R. 4807 would cost $351 million in 2001 and

$6.7 billion over the 2001–2005 period, without adjusting for inflation. The five-year total would be $7 billion if adjustments for inflation are included. The legislation would not affect direct spending

or receipts; therefore, pay-as-you-go procedures would not apply.

H.R. 4807 contains no private-sector mandates as defined in the

Unfunded Mandates Reform Act (UMRA). It does contain an intergovernmental mandate as defined in UMRA, but it also contains

new budget authority for grants that may be used by states to

cover the costs associated with the mandate. Consequently, the

threshold established in UMRA ($55 million in 2000, adjusted annually for inflation) would not be exceeded.

Estimated cost to the Federal Government: The estimated budgetary impact of H.R. 4807 is shown in Table 1. The costs of this

legislation fall within budget function 550 (health).

TABLE 1.—BUDGETARY IMPACT OF H.R. 4807

By fiscal year, in millions of dollars—

2000 2001 2002 2003 2004 2005

SPENDING SUBJECT TO APPROPRIATION

Spending Under Current Law:

Budget Authority 1 ........................................................................... 1,605 0 0 0 0 0

Estimated Outlays ........................................................................... 1,376 1,209 248 64 (2) 0

Without Adjustment for Inflation

Proposed Changes:

Estimated Authorization Level ......................................................... 0 1,711 1,711 1,711 1,711 1,711

48

TABLE 1.—BUDGETARY IMPACT OF H.R. 4807—Continued

By fiscal year, in millions of dollars—

2000 2001 2002 2003 2004 2005

Estimated Outlays ........................................................................... 0 351 1,402 1,608 1,676 1,678

Spending Under H.R. 4807

Estimated Authorization Level 1 ...................................................... 1,605 1,711 1,711 1,711 1,711 1,711

Estimated Outlays ........................................................................... 1,376 1,559 1,650 1,672 1,676 1,678

With Adjustments for Inflation

Proposed Changes:

Estimated Authorization Level ......................................................... 0 1,793 1,766 1,800 1,834 1,866

Estimated Outlays ........................................................................... 0 356 1,431 1,663 1,764 1,798

Spending Under H.R. 4807:

Estimated Authorization Level 1 ...................................................... 1,605 1,739 1,766 1,800 1,834 1,866

Estimated Outlays ........................................................................... 1,376 1,565 1,679 1,728 1,764 1,798

1 The 2000 level is the amount appropriated for that year for title XXVI programs.

2 Less than $500,000.

Basis of estimate: For this estimate, CBO assumes that the bill

will be enacted by the end of fiscal year 2000 and that outlays will

follow historical spending rates for the authorized activities. Where

specified in H.R. 4807, CBO assumes the authorized amounts

would be appropriated. Where appropriations of such sums as necessary are authorized, CBO based its estimates on amounts spent

in the past for similar types of activities. Table 1 shows two alternative spending paths: one assuming no increase to account for inflation, and one with annual inflation adjustments.

Reauthorization of existing programs

The authorizations for appropriations for most of the programs

under the Ryan White CARE Act expire at the end of fiscal year

2000. H.R. 4807 would reauthorize those programs for fiscal years

2001 through 2005. Table 2 shows the amount appropriated in fiscal year 2000, and the estimated authorization levels under H.R.

4807 for fiscal years 2001 through 2005, with adjustments for inflation.

TABLE 2.—TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS

AUTHORIZED IN H.R. 4807, WITH ADJUSTMENTS FOR INFLATION

By fiscal year, in millions of dollars—

2000 2001 2002 2003 2004 2005

Programs Administered by HRSA

Reauthorizations: 1

Part A (Title I of the Ryan White CARE Act) emergency relief

grants .......................................................................................... 547 556 566 576 586 597

Part B (Title II) HIV care grants ..................................................... 824 839 853 868 884 900

Part C (Title III) early intervention services ................................... 138 141 143 146 149 151

Part D (Title IV) pediatric AIDS: women, children, and youth ....... 51 52 53 54 55 56

Part D (Title IV) evaluations and reports ....................................... 0 4 4 4 4 4

Part F demonstration and training AIDS education and training

centers ........................................................................................ 27 27 28 28 29 29

Dental reimbursements ................................................................... 8 8 8 8 9 9

Modifications to Current Programs:

Planning and capacity development grants ................................... 0 6 6 6 6 6

AIDS education and training centers .............................................. 0 15 17 20 20 21

Other activities ................................................................................ 0 6 1 1 1 1

New programs:

Supplemental grants for certain states ineligible for Part A

grants .......................................................................................... 0 0 0 0 3 3

49

1There has never been an appropriation for Part E, which requires the Secretary to make

grants to state and local governments to assist them in disseminating guidelines to emergency

responses employees regarding reducing the risk in the workplace of becoming infected with

AIDS.

TABLE 2.—TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS

AUTHORIZED IN H.R. 4807, WITH ADJUSTMENTS FOR INFLATION—Continued

By fiscal year, in millions of dollars—

2000 2001 2002 2003 2004 2005

Complaint partner notification program ......................................... 0 30 31 31 32 32

Subtotal ....................................................................................... 1,595 1,683 1,709 1,743 1,777 1,808

Programs Administered by CDC

HIV-related services for pregnant women and newborns 1 ..................... 10 30 30 30 30 30

Data collection, reports, and other activities .......................................... 0 25 26 26 26 27

Provisions Administered by NIH

Expansion of HIV research funds for affordable HIV testing and

issuance of reports .............................................................................. 0 1 1 1 1 1

Total Proposed Changes ............................................................. 1,605 1,739 1,766 1,800 1,834 1,866

1 The 2000 level is the amount appropriated for that year.

HRSA Programs. The bill would reauthorize several programs organized under different parts of the Ryan White Care Act: • Part A of title XXVI, (also known as title I of the Ryan White

CARE Act), is the Emergency Relief Grant program. It provides

grants to eligible metropolitan areas (EMAs) severely affected by

the HIV epidemic. The funds are used for outpatient and ambulatory health care and other support services provided by communitybased systems to low-income or under-insured people living with

HIV/AIDS. • Part B, (title II of the act), is the HIV Care Grant program.

It provides grants to states and territories for health care and social support services. Services are delivered primarily through consortia of providers of HIV services. Some Part B funds also are earmarked to pay for drug treatment for certain individuals with HIV

disease. In addition, states may use grant money to help low-income individuals purchase health insurance through Health Insurance Continuation programs. • Part C, (title III of the act), is the Early Intervention Services

program. It awards grants to public and private nonprofit community-based programs that provide comprehensive primary health

care services targeting at-risk populations and aim to reduce or

prevent HIV-related morbidity. • Part D, (title IV of the act), contains general provisions. The

pediatric AIDS: women, children, and youth program provides

funding to improve and expand the primary care and support services for special populations living with HIV disease. The program

aims to increase access to comprehensive, coordinated, communitybased family-centered systems of care for infected individuals and

their families.

• Part F 1 contains the demonstration and training programs. It

authorizes a network of regional centers that conduct HIV/AIDS

education and training programs for healthcare providers, special

projects of national significance relating to the development of innovative models of HIV/AIDS care, and financial assistance to denVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00049 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
50

tal schools for uncompensated oral health care costs for patients

with HIV disease.

CBO estimates that reauthorizing those provisions would cost $325 million in 2001 and $6.6 billion over the 2001–2005 period.

CDC Programs. H.R. 4807 would authorize a CDC-administered

program that provides HIV-related services to pregnant women and

newborns. The bill would authorize the appropriation of $30 million

a year and would expand the services covered under the program.

If at least $10 million is appropriated, part of the amount above

$10 million would be set aside for states that comply with certain

requirements such as mandatory testing. CBO estimates that this

provision would cost $11 million in 2001 and $122 million over the

2001–2005 period.

Modifications to current programs

The bill would make several modifications to existing programs.

Those changes and their estimated budgetary effects are described

below. In total, CBO estimates that implementing these modifications would cost $5 million in 2001 and $102 million over the

2001–2005 period.

Planning and Capacity Development Grants. Section 312 of H.R.

4807 would authorize a program of capacity development grants to

assist public and nonprofit private entities in expanding their ability to provide primary care and early intervention services to individuals with HIV disease in underserved communities. Under current law, a maximum of 1 percent of the amount appropriated for

Part C can be used for planning grants. H.R. 4807 would increase

to 5 percent the proportion that could be earmarked for the new

capacity development grants and the planning grants. The maximum new capacity development grant would be set at $150,000

under the bill. CBO estimates this provision would cost $1 million

in 2001 and $23 million through 2005.

AIDS Education and Training Centers and Dental Reimbursements. H.R. 4807 would allow the Secretary of HHS to fund

projects to develop and disseminate treatment guidelines and protocols for prenatal and gynecological care of women with HIV disease. It also would authorize training of health professionals in

that area. H.R. 4807 would require the Secretary to develop and

implement a strategy for disseminating HIV-related information to

health care providers and patients. The bill also would modify the

dental school grant program to allow partnership agreements between dental programs and community-based dentists to provide

services in unserved areas. Finally, the bill would permit certified

dental hygiene programs to receive reimbursement for uncompensated oral health care services provided to individuals with HIV

disease under the dental reimbursement program. CBO estimates

that those provisions would cost $3 million in 2001 and $71 million

over the 2000–2005 period.

Other HRSA Activities. H.R. 4807 would require that formula

grants reauthorized under Parts A and B use the number of HIV

disease cases and AIDS cases in the distribution formulas in fiscal

year 2005 and subsequent years. This provision would have no direct impact on federal spending. The bill would require the federal

government to assist states with the new data requirements that

would directly raise their program costs.

51

Part A grants. The bill would extend indefinitely the requirement

that 50 percent of appropriated funds for Part A be disbursed within 60 days after the appropriation becomes available. (Those funds

are disbursed in the form of formula grants.) A ‘‘hold harmless’’

provision in the bill would also change the limit on the amount by

which grants to states could decline from year to year. Those provisions would affect the distribution of annual appropriations and the

expedited disbursement might affect the pattern at which such appropriations would be spent during the year (by increasing the

amounts disbursed within 60 days of appropriation), but CBO anticipates that they would not affect total program spending.

Part B grants. Section 206 of the bill would double the minimum

Part B base award to $200,000 for states with fewer than 90 living

cases of AIDS and to $500,000 for states with 90 or more living

cases of AIDS. It would also add the Federated States of Micronesia and the Republic of Palau as entities eligible to receive Part

B funds. The bill also would modify the hold harmless formula for

Part B grants. CBO estimates those changes would cost less than

$500,000 in 2001 and $4 million over the 2001–2005 period.

Additional HRSA activities and reports. H.R. 4807 would require

several new activities by the Secretary of HHS and many new

studies and reports. The Secretary, through the Administrator of

HRSA and in consultation with grant recipients, would be required

to conduct a review of several administrative procedures for grants

provided under Parts A and B, and develop new coordinated and

more efficient procedures. Submission of the various plans for implementing such changes to the Congress would be due within 18

to 24 months of enactment.

The bill also would require that the Secretary provide training

manuals and guidance materials to the Planning Council members

who make allocation decisions about Part A grants. It also would

require that the Secretary develop national quantitative incidence

data and design a mechanism for its use in making awards for the

supplemental grant money that goes to states demonstrating ‘‘severe need.’’

The bill also would require that the Secretary of HHS, in consultation with others, develop a plan regarding appropriate care

following the release of prisoners with HIV disease within two

years following enactment.

H.R. 4807 would require federal coordination among federal HIV

programs concerning planning, funding, and implementation

issues. This provision would affect programs administered by

HRSA, CDC, the Substance Abuse and Mental Health Services Administration, and the Health Care Financing Administration. The

bill would require biannual reports to the Congress with an analysis of the federal barriers to HIV program integration, including

proposals to eliminate those barriers, as well as a status report on

the coordination efforts at the federal, state, and local levels.

The Secretary would be required to request that the Institute of

Medicine (IOM) complete a study, within two years after the enactment of H.R. 4807, regarding the appropriate epidemiological

measures and their relationship to health-related support services

for certain individuals with HIV. The Secretary would have to report to the Congress within 90 days of the request’s completion.

The bill also would require that the Secretary request IOM to conVerDate 11-MAY-2000 06:31 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00051 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
52

duct a study on the reliability of surveillance systems used by the

states and to issue recommendations to improve those systems

within three years of enactment. H.R. 4807 also would require that

the Secretary request IOM to conduct a study within 18 months of

enactment on perinatal transmission of HIV across the states, including an analysis of barriers to the testing of newborns and pregnant women, and to provide state-by-state recommendations to reduce perinatal transmission of HIV.

CBO estimates those activities and reports would cost about $1

million in 2001 and $5 million over 2001 through 2005.

New HRSA programs

In addition to reauthorizing current programs and making certain programmatic changes, the bill would provide authorizations

for two new provisions in the Ryan White CARE Act that would increase program costs. The estimated appropriations authorized in

the bill for these provisions is also shown in Table 2.

New Supplemental Grants for Certain States. Section 207 of H.R.

4807 would create a new supplemental grant program to meet HIV

care and support needs in areas that are not eligible for Part A

grants. The Secretary of HHS would be required to reserve 50 percent of the increase in funding for Part B grants (other than that

earmarked for state AIDS drug assistance programs, or ADAPs) for

these supplemental grants—which would be awarded competitively

to states in ‘‘severe need’’ for additional resources. However, the

program would not begin until the amount appropriated under

Part B (excluding ADAP funds) is $20 million higher than the

amount appropriated in 2000. Under the inflation-adjusted assumptions used for this estimate such a trigger would not be

reached until 2004. CBO estimates that the new program would

have no effect on federal spending in 2001 but would cost $3 million over the 2001–2005 period.

Compliant Partner Notification Program. H.R. 4807 would establish a new grant program for partner notification, counseling, and

referral services. States would have to cooperate with CDC and

comply with certain requirements, including information sharing

between states, to be eligible to receive funds. The bill would authorize $30 million for this program in 2001 and such sums as necessary through 2005. Assuming appropriation of the necessary

amounts, CBO estimates that implementing this provision would

cost $6 million in 2001 and a total of $121 million through 2005.

NIH activities and reports

H.R. 4807 would direct the Secretary, through the Director of the

NIH, to examine the distribution and availability of HIV-related

clinical research programs for women, infants, children, and youth.

Although H.R. 4807 does not require submission of a report to the

Congress, CBO believes the bill’s intent is to have the results of the

evaluation transmitted to the Congress. The bill also would require

that NIH expand its research efforts in the development of rapid

HIV tests and to provide progress reports to the Congress. CBO estimates that those provisions would cost less than $500,000 in 2001

and $5 million over the 2001–2005 period.

53

CDC activities and reports

H.R. 4807 would authorize a new program for CDC to collect

data and provide information support to the Ryan White program

and its grantees for planning and evaluation activities. Based on

the resources CDC currently devotes to supporting the improvement of states’ HIV surveillance systems, CBO estimates that up

to an additional 40 percent of that amount would be needed, or

about $25 million starting in fiscal year 2001. It also would require

that the Secretary, in consultation with CDC and the Food and

Drug Administration, submit an analysis of issues surrounding premarket reviews and commercial distribution of rapid HIV tests of

the Congress within 90 days of enactment. In addition, the bill

would require the CDC to establish guidelines for the use of rapid

HIV tests, with specific recommendations for states, hospitals, and

other entities on the availability of HIV tests for administration to

pregnant women in labor or in late-stage pregnancy with unknown

HIV status. CBO estimates that those activities and reports would

increase costs by $9 million in 2001 and $105 million over the

2001–2005 period.

Pay-as-you-go considerations: None.

Estimated impact on state, local, and tribal governments: The

bill contains an intergovernmental mandate as defined in UMRA

because it would require states to implement recommendations by

the Institute on Medicine for increasing the routine testing of pregnant women and newborn children for HIV. States would be required to submit reports that describe their progress toward implementing the recommendations and barriers in the state that inhibit

an obstetrician’s ability to routinely test pregnant women and newborn infants for HIV.

The bill also would authorize $30 million annually in grants for

testing and treating case of perinatal HIV. CBO assumes that

states would be allowed to use these grants to comply with the

intergovernmental mandate and that the costs of the mandate

would be well below that amount. The bill also would expand the

purposes for which a number of grants could be used, including

outpatient ambulatory and support services, inpatient case management, and early intervention. Additional requirements for

grants include increased outreach, data collection, and implementation of quality management procedures. Such requirements would

not be intergovernmental mandates as defined in UMRA because

they are conditions of federal assistance.

Estimated impact on the private sector: The bill contains no private-sector mandates as defined in UMRA.

Previous CBO estimate: On May 10, 2000, CBO transmitted a

cost estimate for S. 2311, the Ryan White CARE Act Amendments

of 2000, as ordered reported by the Senate Committee on Health,

Education, Labor, and Pensions on April 12, 2000. The two bills

would make different changes to the Ryan White CARE Act, and

the two estimates reflect those differences.

Estimated prepared by: Federal Costs: For HRSA: Julia M.

Christensen. For CDC: Jeanne M. De Sa. For NIH: Christopher J.

Topoleski. Impact on State, Local, and Tribal Governments: Leo

Lex. Impacts on the Private Sector: Jennifer Bullard.

Estimate approved by: Peter H. Fontaine, Deputy Assistant Director for Budget Analysis.

54

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates prepared by the Director of the Congressional Budget Office

pursuant to section 423 of the Unfunded Mandates Reform Act.

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the

Federal Advisory Committee Act were created by this legislation.

CONSTITUTIONAL AUTHORITY STATEMENT

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House

of Representatives, the Committee finds that the Constitutional authority for this legislation is provided in Article I, section 8, clause

3, which grants Congress the power to regulate commerce with foreign nations, among the several States, and with the Indian tribes.

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the

terms and conditions of employment or access to public services or

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act.

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Short title; table of contents

This section provides the short title of the legislation, the ‘‘Ryan

White CARE Act Amendments of 2000,’’ and includes a table of

contents.

TITLE I—EMERGENCY RELIEF FOR AREAS WITH

SUBSTANTIAL NEED FOR SERVICES

Subtitle A—HIV Health Services Planning Councils

Section 101. Membership of councils

Subsection (a) changes the requirements for representation on an

HIV Health Services Planning Council. Under current law, the

Council must reflect in its composition the demographics of the epidemic in the eligible area. New language requires that the Council

reflect in its composition the demographics of the population of individuals with HIV disease in the eligible area. This subsection

clarifies the requirement that representatives to the Council from

affected communities must include people with HIV disease. Representatives to the Council who are grantees under other Federal

HIV programs may include providers of HIV prevention services.

This subsection also adds the new requirement that the Council include representatives of individuals who formerly were Federal,

State, or local prisoners, were released from the custody of the

penal system during the preceding three years, and had HIV disease when so released.

Subsection (b) establishes a new requirement that at least 33%

of the Council must be individuals who are receiving HIV-related

services under Part A, the Emergency Relief Grant Program, must

not be officers, employees, or consultants to any entity receiving

55

such a grant, and do not represent such entity. An individual will

be considered as receiving such services if the individual is the parent or caregiver of a minor child who is receiving HIV services.

This restriction does not apply to entities receiving grants under

other parts of the Ryan White CARE Act.

Section 102. Duties of councils

Section 102(a) adds to the duties of the HIV Health Service Planning Council the requirements to determine the size and demographics of the population of individuals with HIV disease and the

needs of the population, with particular attention to individuals

with HIV disease who are not receiving HIV-related services, and

disparities in access and services among affected subpopulations

and historically underserved communities.

This provision also rewrites current law on priorities that the

Council must take into account in allocating of funds. The Council

must take into account the size and demographics of the population

with HIV disease; the demonstrated (or probable) cost effectiveness

and outcome effectiveness of proposed strategies; the priorities of

the communities for whom the services are intended; the availability of government and nongovernmental sources of funding, including Medicaid and the SCHIP program; and the capacity development needs in historically underserved areas. In developing a

comprehensive plan for the organization and delivery of health and

support services, the Council must include a strategy for identifying individuals with HIV disease who are not receiving services

and for enabling such individuals to utilize the services, giving particular attention to eliminating disparities, and including discrete

goals, a timetable, and an appropriate allocation of funds and a

strategy to coordinate the provision of such services with programs

for HIV prevention and for the prevention and treatment of substance abuse. The plan must be compatible with any State or local

plan providing HIV services. The Council must coordinate with

Federal grantees that provide HIV-related services within their

area.

After receipt of a report by the Institute of Medicine, the Secretary of Health and Human Services, in consultation with entities

that receive grants under Part A and Part B, must develop epidemiologic measures for establishing the number of individuals living with HIV disease who are not receiving HIV-related services

and carrying out the duties of the Council.

The Secretary must provide guidelines and materials for training

members of the planning Council regarding their duties to each

chief elected official receiving a grant under Part A.

Section 103. Open meetings; other additional provisions

This section sets forth additional provisions with respect to public deliberations of the Planning Council. The Council may not be

chaired solely by an employee of the grantee under Part A. Further, Council meetings must be open to the public and held after

adequate notice and documents prepared by or made available to

the Council must be made available for public inspection and copying. The Council must keep detailed minutes and their accuracy

must be certified by the Council chair. This section does not apply

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to the disclosure of personal information that would constitute an

invasion of privacy, including medical or personnel matters.

Subtitle B—Type and Distribution of Grants

Section 111. Formula grants

Subsection (a) changes current law, which states that Part A

grant funds for eligible areas must be distributed not later than 60

days after such funds are made available ‘‘for each of the fiscal

years 1996 through 2000.’’ The amendment applies to a generic fiscal year.

Subsection (b) provides that, for grants made for FY2005 and

subsequent fiscal years, the cases counted for each 12-month period

beginning on or after July 1, 2004, must be cases of HIV disease

(as confirmed by the Centers for Disease Control and Prevention(CDC)) rather than cases of acquired immune deficiency syndrome as under current law. The update of the yearly percentages

used to determine grant amounts must be reported to the congressional committees of jurisdiction and, as applicable, the updates

must take into account HIV cases. This subsection also requires the

Secretary to determine whether sufficiently accurate and reliable

data exists on cases of HIV disease. If the Secretary determines,

by July 1, 2004, that there is not sufficiently accurate and reliable

data on cases of HIV disease from all eligible areas, then references

in this section to cases of HIV disease do not have any legal effect.

From amounts appropriated for CDC grants on data collection, the

Secretary is required to reserve funds to make grants and provide

technical assistance to States and eligible areas for obtaining data

on cases of HIV disease to ensure that data on such cases is available from all States and eligible areas as soon as practicable but

not later than the beginning of FY2007.

Subsection (c) revises the limitation on the reduction in funding

for a grant from one fiscal year to the next which may occur in certain eligible areas. Under current law, grants made under Part A

for fiscal year 2000 cannot be less than 95% of the amount received

by the eligible area in fiscal year 1995. This provision stipulates

that for each fiscal year in a protection period for an eligible area,

the amount of the grant is increased to ensure that: (1) for the first

fiscal year in the protection period, the grant is not less than 98%

of the amount of the grant made for the base year for the protection period; (2) for any second fiscal year in such period, the grant

is not less than 95.7% of the base year grant; (3) for any third fiscal

year in such period, the grant is not less than 91.1% of the base

year grant; (4) for any fourth fiscal year, the grant is not less than

84.2% of the base year grant; and (5) for any fifth or subsequent

fiscal year in such period, the grant is not less than 75% of the

base year grant. This provision also defines the base year for a protection period as the fiscal year preceding the trigger grant-reduction year. Further, it defines the first trigger grant-reduction year

as the first fiscal year (after FY2000) for which the grant for the

area is less than the grant for the preceding fiscal year. A protection period begins with the trigger grant-reduction year and continues until the beginning of the first fiscal year for which the

grant equals or exceeds the amount of the grant for the base year.

Any subsequent trigger grant-reduction year is the first fiscal year

57

after the end of the preceding protection period, for which the grant

is less than the grant for preceding fiscal year.

Section 112. Supplemental grants

Current law provides a series of factors to be given priority consideration in awarding supplemental grants. Subsection (a) directs

that the Secretary must count ‘‘severe need’’ as one-third when

weighing factors to determine supplemental grant amounts. It also

adds as new factors in determining severe need the current prevalence of HIV disease, the increasing need for HIV-related services,

and unmet need for such services. Further, it directs the Secretary

to develop a mechanism to use national, quantitative incidence

data not later than 18 months after the enactment. The mechanism

should be modified to reflect the findings of the IOM report on epidemiological measures and health care for individuals with HIV

disease.

Subsection (b) makes conforming amendments to the statute.

Subtitle C—Other Provisions

Section 121. Use of amounts

The legislation makes some technical changes to the general primary purposes for the use of grant funds under Part A regarding

outpatient and ambulatory health or support services, and inpatient case management. Subsection (a) specifically defines outpatient and ambulatory support services as including case management, to the extent that such services facilitate, support, or sustain

the delivery, or benefits of health services. It also includes outreach

activities as a new general primary purpose for the use of grant

amounts. The outreach activities are intended to identify individuals with HIV disease who are not receiving HIV-related services.

Subsection (b) authorizes the use of Title I grants for early intervention services. (Under current law, such services are only provided under Title III.) The entities which may receive grants for

such services include: public health departments, emergency rooms,

substance abuse and mental health treatment programs, detoxification centers, detention facilities, clinics regarding sexually transmitted diseases, homeless shelters, HIV disease counseling and

testing sites, State health care points of entry or eligible areas, federally qualified health centers, and entities providing early intervention services. The entity must demonstrate to the chief elected

official that Federal, State, or local funds are inadequate for the

services to be provided and that the entity will supplement and not

supplant other available funds for such services.

Subsection (c) specifies that the chief elected official must establish a quality management program to assess the extent to which

services are consistent with Public Health Service guidelines for

the treatment of HIV disease, and as applicable, to develop strategies to ensure that such services are consistent with the guidelines.

Restricts spending on such program to the lesser of 5% of the Title

I grant received or $3 million.

Section 122. Application

In addition to other assurances specified under current law that

are to be included on an application, entities within an eligible area

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that receive grant funds must maintain relationships with appropriate entities in the area, including those conducting early intervention services.

Section 123. Review of administrative costs and compensation

Each chief elected official must ensure, not later than one year

after the date of enactment of this legislation, that the planning

Council reviews available data on the administrative costs (including financial compensation and benefits) of entities receiving

grants; and determines whether compensation of any officers or

employees of such entities exceeds that of the chief elected official.

TITLE II—CARE GRANT PROGRAM

Subtitle A—General Grant Provisions

Section 201. Priority for women, infants, and children

Under current law, a priority for services is provided for women,

infants, and children; this section adds youth to this group.

Section 202. Use of grants

Under current law, Part B grants funds may be used to provide

a variety of health services for individuals and families with HIV

disease including: outpatient and ambulatory health and support

services; inpatient case management; outreach activities; establishment and operation of HIV care consortia; home-based and community-based care services; continuity of health insurance coverage;

and, therapeutics to treat HIV disease. This section specifies that

States may use Part B grant funds for: (1) support services, including case management, to the extent that such services facilitate,

support, or sustain the delivery, or benefits of health services for

individuals and families with HIV disease; (2) outreach activities

that are intended to identify individuals with HIV disease who are

not receiving HIV-related services; (3) early intervention services

(under current law, such services are only provided under Title III);

and (4) quality management program to assess the extent to which

services are consistent with Public Health Service guidelines for

the treatment of HIV disease, and as applicable, to develop strategies to ensure that such services are consistent with the guidelines.

It also restricts spending on quality management to the lesser of

5% of the Part B grant received or $3 million. (The guidelines and

restrictions governing Part B grants for quality management are

the same as those required for Part A.)

Section 203. Grants to establish HIV CARE consortia

This section adds new language regarding the assurances and

the application submitted by a consortium to a State for Part B

grant assistance. Current law requests that a consortium provide

a number of assurances along with the application to a State for

Part B grant funds. It stipulates that a consortium must provide

the State with assurances that it has identified populations with

HIV disease, particularly those experiencing disparities in access

and services and those who reside in historically underserved communities. In addition, the consortium must provide assurances that

its service plan is consistent with the State comprehensive plan for

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the organization and delivery of HIV health care and support services. The consortium must also demonstrate in the application for

Part B grant funds that adequate planning occurred to address disparities in access and services in historically underserved communities.

Section 204. Provision of treatments

This section makes changes in how States may use funds under

Part B to provide treatments for individuals with HIV disease.

Current law authorizes States to provide prescription drugs to lowincome individuals with HIV disease. New language allows a State

to expend grants to pay, on behalf of individuals with HIV disease,

the costs of purchasing or maintaining health insurance or plans

whose coverage includes a full range of such therapeutics and appropriate primary care services.

Section 205. State application

Subsection (a) makes additions to the information that must be

included in the State application for Part B funds (these changes

are similar to those made to the duties of the Planning Council

under Title). This subsection specifies that a State application must

contain determinations of: (1) the size and demographics of the

population of individuals with HIV disease; and (2) the needs of the

population, with particular attention to individuals with HIV disease who are not receiving HIV-related services, and disparities in

access and services among affected subpopulations and historically

underserved communities.

The State application must provide a comprehensive plan that,

in addition to current law requirements, establishes priorities for

the allocation of funds based on: size and demographics of the population with HIV disease; the availability of other governmental

and nongovernmental resources; the capacity development needs

resulting from disparities in the availability of HIV-related services

in historically underserved communities and rural communities;

and the efficiency of the administrative mechanism of the State for

rapidly allocating funds to the areas of greatest need. The comprehensive plan must also include: (1) a strategy for identifying individuals with HIV disease who are not receiving services and for

enabling such individuals to utilize the services, giving particular

attention to eliminating disparities, and including discrete goals, a

timetable, and an appropriate allocation of funds; and (2) a strategy to coordinate the provision of such services with programs for

HIV prevention and for the prevention and treatment of substance

abuse.

Subsection (b) revises the public hearing process. Current law

provides that the public health agency administering the grant for

the State will conduct public hearings concerning the proposed use

and distribution of funds received under Part B. This subsection

specifies that the public health agency administering the grant for

the State must engage in a public advisory planning process, including public hearings, when developing the comprehensive plan

for the State application. This public advisory planning process

must include the same participants represented when developing

the statewide coordinated statement of need and shall to the extent

possible include entities described in section 2602(b)(2).

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Subsection (c) requires that, along with the State application for

Part B funds, the State must provide an assurance that entities located within areas in which grant activities are carried out must

maintain relationships with appropriate entities in the area, including those providing early intervention services.

Section 206. Distribution of funds

Subsection (a) doubles the minimum allotments for grants under

Part B. For States with less than 90 living cases of AIDS, the minimum grant is $200,000 instead of $100,000 in current law. The

minimum grant for States with 90 or more living cases of AIDS is

$500,000 instead of $250,000 in current law. In addition, each territory is eligible for a minimum funding level of $50,000; current

law does not provide a minimum funding level for territories.

Current law uses an estimate of the number of living cases of

AIDS within the State or territory in the formula which determines

the amount of a State grant under Part B. Subsection (b) provides

that when estimating living cases for grants made for FY2005 and

subsequent fiscal years, the cases counted for each 12–month period beginning on or after July 1, 2004, shall be cases of HIV disease (as confirmed by CDC) rather than cases of AIDS, as in current law. However, if the Secretary determines by July 1, 2004,

that there is not sufficiently accurate and reliable data on cases of

HIV disease from all eligible areas, then references in this section

to cases of HIV disease do not have any legal effect.

Subsection (c) revises the limitation on the reduction in funding

for a grant from one fiscal year to the next which may occur in certain States.

Subsection (d) provides that each territory is eligible for a min- imum funding level of $50,000, duplicating a change made in this

bill by section 206, subsection (a).

Subsection (e) authorizes the Secretary to reserve 2% of AIDS

drug assistance program funds to make grants to States whose

HIV patients have a need for therapeutics that is not being met by

the current ADAP program within the State. These grants are discretionary grants and not formula grants. It also requires such

grants to be distributed not later than 240 days after ADAP funds

become available. States must match such grants with non-federal

contributions of not less than 25% of the costs.

In current law, the term ‘‘territory of the United States’’ is defined as American Samoa, the Commonwealth of the Northern

Mariana Islands and the Republic of the Marshall Islands. ‘‘State’’

is defined as the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, and Guam. Subsection (f)

amends the definition of the territories to include the Federated

States of Micronesia, the Republic of Palau, and for purposes of determining minimum grant level, the Commonwealth of Puerto Rico.

Section 207. Supplemental grants for certain states

This section removes a section of current law, which is replaced

by section 413. A new supplemental grant program is created for

States that have eligible communities with a severe need for comprehensive HIV-related services and which are not eligible for

grants under Part A. States must submit an application that details the need for services in such communities. The program beVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00060 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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comes effective when the amount appropriated to Title II (excluding ADAP) is at least $20 million greater than the appropriation

for Title II in FY2000.

Subtitle B—Provisions Concerning Pregnancy and Perinatal

Transmission of HIV

Section 211. Repeals

This section repeals provisions regarding the testing of pregnant

women and newborn infants.

Section 212. Grants

Subsection (a) includes treatment services, in accordance with

applicable recommendations of the Secretary, for pregnant women

(with HIV disease) and their infants as an additional purpose for

making grants. Under current law, this section allows the Secretary to make grants to States that have adopted the CDC guidelines on HIV counseling and voluntary testing of pregnant women.

Such grants are used for: counseling pregnant women on HIV disease; outreach efforts to women at risk of HIV who are not receiving prenatal care; voluntary testing; and, offsetting various State

costs in implementing this section. Authorizes $30 million for each

of fiscal years 2001 through 2005. When such appropriations are in

excess of $10 million, the Secretary must reserve a percentage for

making grants to States that under law have a requirement that

all newborn infants be tested for HIV disease; or a requirement

that newborn infants born in the State be tested for HIV disease

where the attending obstetrician does not know the HIV status of

the mother. The percentages to be reserved are: 25% for FY2001,

50% for FY2002, 50% for FY2003, 75% for FY2004, and 75% for

FY2005. No grant may exceed $4 million and if the reserved

amounts are not obligated, then the requirement to reserve such

amounts will not apply. A State in receipt of such funds under this

section must agree that the grant will supplement and not supplant other available funds to carry out the purposes of the grant.

Subsection (b) establishes a special funding rule if FY2001 appropriations are less than $14 million for this section. The Secretary

is required to reserve certain amounts from increased FY2001

funding for Title II that is above such appropriations for FY2000.

Section 213. Study by Institute of Medicine

This section adds a new section requiring the Secretary to request that the Institute of Medicine conduct a study to: (1) determine the number of newborn infants with HIV born in the United

States where the attending obstetrician did not know the HIV status of the mother; (2) determine State barriers that prevent or discourage an obstetrician from making it a routine practice to offer

pregnant women an HIV test and a routine practice to test newborn infants for HIV disease in circumstances in which the obstetrician does not know the HIV status of the mother; and (3) provide

recommendations for each State for reducing perinatal transmission of HIV. It requires the report to be submitted to the appropriate congressional committees, the Secretary, and the chief public

health official of each State. Beginning in FY2004, each State is required to report to the Secretary on progress being made toward

62

meeting such recommendations. For FY2005 and each subsequent

fiscal year, the State must demonstrate that it has made reasonable progress toward meeting the recommendations. If the State

has not made reasonable progress, the State must cooperate with

the CDC Director in carrying out activities toward meeting the recommendations, and the State must submit a report to the Secretary containing a description of any barriers that continue to

exist in the State and a description of how the State intends to reduce the incidence of perinatal HIV cases. The Secretary must

make funds under section 212 grants available to the States for the

purposes of this section and is required to submit the State reports

to the appropriate congressional committees.

The Committee recognizes that the IOM completed a report on

this topic in 1998. It is not the intent of the Committee to duplicate

any material compiled for that report. The study is to make broad

recommendations for each State to and assist States in reducing

the incidence of perinatal HIV transmission. The Committee recognizes that some States have had few, if any, such cases in recent

years. An analysis of the efforts of these states may provide useful

information to states that continue to have higher rates of

perinatal HIV transmission.

Subtitle C—Certain Partner Notification Programs

Section 221. Grants for compliant partner notification programs

This section adds a new subpart to the Ryan White CARE Act

that provides grants for partner notification programs. It authorizes appropriations of $30 million for FY2001 and such sums as

necessary for each of the fiscal years 2002 through 2005 for grants

to States to carry out programs to provide partner counseling and

referral services. In order to receive a grant under this new subpart, a State must have the following policies in effect: (1) a program for partner notification to inform partners of individuals with

HIV disease that the partners may have been exposed to HIV; (2)

a system for confidentially reporting positive test results for HIV;

(3) specific counseling and referral measures; (4) reports to CDC on

the number of individuals solicited for names of partners, the number who provided the names, and the number of notified partners;

(5) cooperation with CDC in a national program of partner notification in which information is shared between public health officers

of the States. In making grants, the Secretary must give preference

for each of the fiscal years FY2001 through FY2003 to States

whose reporting systems for cases of HIV disease produce sufficiently accurate and reliable data. A State may not receive a grant

for FY2004 or subsequent fiscal years unless its reporting system

produces reliable data.

TITLE III—EARLY INTERVENTION SERVICES

Subtitle A—Formula Grants for States

Section 301. Repeal of program

This section repeals subpart I of part C of title XXVI of the

PHSA. (Subpart I was not reauthorized in 1995.) Subpart I provided formula grants to States for early intervention services such

as HIV testing and counseling, other clinical or diagnostic services,

63

and referrals to providers of health support services or biomedical

research facilities.

Subtitle B—Categorical Grants

Section 311. Preferences in making grants

Under current law, the Secretary must give preference to any

qualified applicants that are experiencing an increase in the burden of providing services regarding HIV disease. This new provision adds that the Secretary must give preference to those that will

expend the grant to provide services in underserved or rural areas.

Section 312. Planning and development grants

Current law allows the use of planning and development grants

to assist entities in expanding their capacity to provide early intervention services. Subsection (a) provides that the grants are to be

used to assist entities in expanding their capacity to provide services, including early intervention, in low-income communities and

affected subpopulations that are underserved. Such grants may not

be used to purchase or improve land, or to purchase, construct, or

permanently improve any building or other facility.

Current law provides that planning grants under this section to

provide early intervention services may not exceed $50,000. Subsection (b) specifies that grants for early intervention services

under paragraph (1)(A) may not exceed $50,000, and grants for capacity development for low-income and underserved populations

under paragraph (1)(B) may not exceed $150,000 and their duration may not exceed three years.

Subsection (c) increases to five percent (currently one percent)

the amount of appropriations for this subpart that may be used to

carry out this section.

Section 313. Authorization of appropriations

This section extends authorized appropriations of such sums as

necessary for this subpart for each of the fiscal years 2001 through

2005.

Subtitle C—General Provisions

Section 321. Provision of certain counseling services

Presently, current law specifies what additional information

(such as early interventions services, health care referrals) is to be

conveyed to an individual receiving a positive result on an HIV

test. This section adds new language specifying that when grant

applicants counsel individuals regarding a positive HIV test result,

they must provide counseling that: (1) emphasizes the duty of infected individuals to disclose their infected status to their sexual

partners and their partners in the sharing of hypodermic needles;

(2) provides advice on the manner in which such disclosures can be

made; and (3) emphasizes the continuing duty to avoid any behaviors that will expose others to HIV.

Section 322. Additional required agreements

This section adds new language provides that the applicant will

not expend more than 10%, instead of the current 7.5%, for adminVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00063 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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istrative expenses, including planning and evaluation of the grant.

In addition, new language specifies that applicants are required to

establish a quality management program to assess the extent to

which medical services under this title are consistent with the most

recent Public Health Service guidelines for the treatment of HIV

disease and related opportunistic infections and that improvements

in access to and quality of medical services are addressed.

TITLE IV—OTHER PROGRAMS AND ACTIVITIES

Subtitle A—Certain Programs for Research, Demonstrations, or

Training

Section 401. Grants for coordinated services and access to research

for women, infants, children, and youth

This section removes language in current law specifying that a

significant number of women, infants, children and youth who are

patients of the applicant will be participating in research projects.

This section provides new language specifying that grant applicants must demonstrate linkages to research and how access to

such research is being offered to patients. The Secretary, in coordination with the Director of the National Institutes of Health (NIH),

is required to examine the distribution and availability of appropriate HIV-related research projects to enhance and expand HIVrelated research, especially in communities that are under represented with respect to such projects. Grantees must also implement a quality management program. Authorized appropriations

are extended through FY2005.

Section 402. AIDS education and training centers

The Committee believes that the Dental Reimbursement Program is a cost-effective program that provides quality oral health

care to people living with HIV/AIDS, and trains providers to effectively and safely deliver care to these patients. The Committee has

reauthorized the program and maintained its current format of providing retrospective reimbursement to dental schools and residency

programs. In addition, the Committee has established new grants

for community-based care to support collaborative efforts between

dental education programs and community-based providers directed at providing oral health care to patients with HIV disease

in currently unserved areas and communities without dental education programs.

Although the Dental Program has been successful, there is still

a large HIV/AIDS population that has not benefitted because there

is not a dental education institution participating in their area.

These patients are also in need of dental services that could be provided at community sites if more community-based providers would

partner with a dental school or residency program. In these partnerships, dental students or residents could provide treatment for

HIV/AIDS patients in underserved communities under the direction of a community-based dentist who would serve as adjunct faculty. By encouraging dental educational institutions to partner

with community-based providers, the Committee intends to address

the unmet need in these areas by ensuring that dental treatment

65

for the HIV/AIDS population is available in all areas of the country, not just where dental schools are located.

Current law allows eligible entities to use grant funds for the

training of health personnel in the diagnosis, treatment and prevention of HIV disease, including the prevention of the perinatal

transmission of the disease and the prevention and treatment of

opportunistic infections. Subsection (a) provides that grants may be

used to train health professionals in prenatal and other gynecological care for women with HIV disease. The Secretary may also

make grants to such entities to develop protocols for the medical

care of women with HIV disease, including prenatal and other gynecological care. In addition, the bill directs the Secretary to, not

later than 90 days after enactment, issue and begin implementation of a strategy for the dissemination of HIV treatment information to health care providers and patients.

Under current law, the Secretary may make grants to assist

schools and programs with respect to oral health care to patients

with HIV disease. Such schools and programs include: (1) dental

schools and post doctoral dental education programs; and (2) dental

hygiene programs that are accredited by the Commission on Dental

Accreditation. Subsection (b) provides that the Secretary may also

make grants to schools and programs, as described in the previous

sentence, that partner with community-based dentists to provide

oral health care to patients with HIV disease in unserved areas.

The partnerships must permit the training of dental students and

residents and the participation of community dentists as adjunct

faculty.

Subsection (c) authorizes appropriations of such sums as necessary for programs under this section for fiscal years 2001

through 2005.

Subtitle B—General Provisions in Title XXVI

Section 411. Evaluations and reports

This section authorizes appropriations for the Secretary to evaluate programs under the Ryan White CARE Act for each of the fiscal years 2001 through 2005.

Section 412. Data collection through centers for disease control and

prevention

This section redesignates section 2675 as section 2675A, and

adds a new section 2675 which authorizes appropriations to the

Secretary (acting through the Director of CDC) of such sums as

may be necessary for each of the fiscal years 2001 through 2005 to

collect and provide data for program planning and evaluation activities. That authorization is in addition to other authorizations

for such purpose.

Section 413. Coordination

Current law provides that the Secretary will assure that the

Health Resources and Services Administration (HRSA) and CDC

will coordinate the planning and funding of programs authorized

under this title to assure that health support services for individuals with HIV disease are integrated with each other and that the

continuity of care of individuals with HIV is enhanced. This section

66

provides that the Secretary must ensure that there is coordination

of the planning, funding, and implementation of Federal HIV programs regarding continuity of care and prevention services among

the following agencies: HRSA, CDC, SAMHSA, and the Health

Care Financing Administration (HCFA). In addition, the Secretary

must consult with other Federal agencies, including the Department of Veterans Affairs, as needed and utilize planning information submitted to such agencies by the States. This section also requires that the Secretary report biennially to the appropriate congressional committees on the coordination efforts at the Federal,

State, and local levels. The report should include a description of

Federal barriers to HIV program integration and a strategy for

eliminating such barriers. It also inserts ‘‘prevention services’’ after

the term ‘‘continuity of care’’ each place the term appears.

Section 414. Plan regarding release of prisoners with HIV disease

This section adds a new subsection to section 2675A which directs the Secretary to develop a plan for the medical case management of and the provision of support services to individuals who

were Federal or State prisoners and had HIV disease on the date

they were released from custody. The Secretary must consult with

the Attorney General, the Director of the Bureau of Prisons, the

States, eligible areas and certain grant recipients in developing

such plan. The Secretary must report to the Congress on such a

plan not later than two years after the date of enactment of this

legislation.

Section 415. Audits

Section 2675B stipulates that for FY2002 and subsequent fiscal

years, the Secretary may reduce grant amounts to a State or political subdivision of a State for a fiscal year, if the State or subdivision fails to prepare audits for the second preceding fiscal year. The

Secretary must annually submit representative samples of such audits to the Congress.

Section 416. Administrative simplification

Section 2675C requires the Secretary, after consultations with

specified entities receiving grants under this title, to: (1) Develop

a plan for coordinating the disbursement of grants to eligible areas

under Part A with the disbursement of grants to States under Part

B; (2) make a determination on whether the efficiency of grantees

would be improved by their submitting applications biennially

rather than annually; and (3) develop a plan for simplifying the

process for applications by eligible areas under Part A and States

under Part B. The Secretary must submit both plans to the Congress not later than 18 months after the date of enactment of this

bill. The Secretary must submit the determination to Congress not

later than 2 years after the date of enactment. The Secretary must

complete implementation of both plans not later than 2 years after

the date of their submission.

Section 417. Authorization of appropriations for Parts A and B

This section authorizes appropriations for fiscal years 2001

through 2005 to carry out Part A (Title I) grants to eligible areas,

and Part B (Title II) CARE grants to States.

67

TITLE V—GENERAL PROVISIONS

Section 501. Studies by Institute of Medicine

Subsection (a) requires that the Secretary ask the Institute of

Medicine to conduct a study that provides the following: (1) a determination of whether the surveillance system of each State regarding HIV provides for the reporting of cases of infection in a manner

that is sufficient to provide adequate and reliable information on

the number of such cases and the demographic characteristics of

such cases, both for the State in general and for specific geographic

areas; (2) a determination of whether such information is sufficiently accurate for purposes of grant formulas to eligible areas

under Part A and States under Part B; and (3) recommendations

on the manner in which a State can improve its surveillance system.

Subsection (b) requires that the Secretary ask the Institute of

Medicine to conduct a study on appropriate epidemiologic measures

and their relation to the financing and delivery of health services

to low-income, uninsured and underinsured people living with HIV

disease. The study should consider existing and needed health care

and epidemiological data and its relation to efficiency and effectiveness of care delivery, quality of care, resource allocation, and access

to HIV services. The study should also determine the actual costs,

potential savings, and financial impact of modifying the Medicaid

program to establish eligibility for medical assistance on the basis

of HIV infection rather than providing assistance only if the infection has progressed to AIDS.

Subsection (c) authorizes the Secretary to contract with other entities if the Institute of Medicine declines to conduct the study.

Subsection (d) directs the Secretary to report to the appropriate

congressional committees not later than three years after the date

of enactment of this Act for the surveillance study, and not later

than two years after enactment for the epidemiological study.

Section 502. Development of rapid HIV test

Subsection (a) requires the Director of NIH to expand, intensify,

and coordinate research and other activities of NIH for the development of reliable and affordable tests for HIV disease that can rapidly be administered and whose results can be rapidly obtained.

Requires periodic progress reports to the appropriate congressional

committees. It also authorizes appropriations as necessary for

FY2001 through 2005.

Subsection (b) requires that the Secretary, in consultation with

the Director of CDC and the Commissioner of Food and Drugs, submit to the appropriate committees a report describing the progress

made towards, and barriers to, the premarket review and commercial distribution of rapid HIV tests. The report must (1) to assess

the public health need for, and benefits of, rapid HIV tests; (2)

make recommendations regarding the need for expedited review of

rapid HIV test applications submitted to the Center for Biologics

Evaluation and Research (including criteria for expedited review

for favorable recommendations); and (3) specify whether the barriers to premarket review include the unnecessary application of

requirements concerning donor screening.

68

Subsection (c) requires that the Director of CDC, promptly after

commercial distribution of a rapid HIV test begins, establish or update guidelines that include recommendations for States, hospitals,

and other appropriate entities regarding the ready availability of

such tests for administration to pregnant women who are in labor

or in the late stage of pregnancy and whose HIV status is not

known to the attending obstetrician.

TITLE VI—EFFECTIVE DATE

Section 601. Effective date

This section establishes the effective date of the legislation as October 1, 2000, or upon the date of its enactment, whichever occurs

later.

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the

House of Representatives, changes in existing law made by the bill,

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic,

existing law in which no change is proposed is shown in roman):

PUBLIC HEALTH SERVICE ACT

* * * * * * *

TITLE XXVI—HIV HEALTH CARE

SERVICES PROGRAM

PART A—EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED

FOR SERVICES

* * * * * * *

SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL.

(a) * * *

(b) HIV HEALTH SERVICES PLANNING COUNCIL.— (1) ESTABLISHMENT.—To be eligible for assistance under this

part, the chief elected official described in subsection (a)(1)

shall establish or designate an HIV health services planning

council that shall reflect in its composition the ødemographics

of the epidemic in the eligible area involved,¿ demographics of

the population of individuals with HIV disease in the eligible

area involved, with particular consideration given to disproportionately affected and historically underserved groups and subpopulations. Nominations for membership on the council shall

be identified through an open process and candidates shall be

selected based on locally delineated and publicized criteria.

Such criteria shall include a conflict-of-interest standard that

is in accordance with paragraph (5).

(2) REPRESENTATION.—The HIV health services planning

council shall include representatives of—

(A) * * *

* * * * * * *

69

(G) affected communities, including people with HIV disease øor AIDS¿ and historically underserved groups and

subpopulations;

* * * * * * *

(K) grantees under section 2671, or, if none are operating in the area, representatives of organizations with a

history of serving children, youth, women, and families living with HIV and operating in the area; øand¿

(L) grantees under other Federal HIV programsø.¿, including but not limited to providers of HIV prevention services; and

(M) representatives of individuals who formerly were

Federal, State, or local prisoners, were released from the

custody of the penal system during the preceding three

years, and had HIV disease as of the date on which the individuals were so released.

(3) METHOD OF PROVIDING FOR COUNCIL.—

(A) * * *

* * * * * * *

ø(C) CHAIRPERSON.—A planning council may not be

chaired solely by an employee of the grantee.¿

* * * * * * *

(4) DUTIES.—The planning council established or designated

under paragraph (1) shall—

(A) determine the size and demographics of the population of individuals with HIV disease;

(B) determine the needs of such population, with particular attention to—

(i) individuals with HIV disease who are not receiving HIV-related services; and

(ii) disparities in access and services among affected

subpopulations and historically underserved communities;

ø(A)¿ (C) establish priorities for the allocation of funds

within the eligible area, including how best to meet each

such priority and additional factors that a grantee should

consider in allocating funds under a grant based on the—

ø(i) documented needs of the HIV-infected population;

ø(ii) cost and outcome effectiveness of proposed

strategies and interventions, to the extent that such

data are reasonably available (either demonstrated or

probable);

ø(iii) priorities of the HIV-infected communities for

whom the services are intended; and

ø(iv) availability of other governmental and nongovernmental resources;¿

(i) size and demographics of the population of individuals with HIV disease (as determined under subparagraph (A)) and the needs of such population (as

determined under subparagraph (B));

(ii) demonstrated (or probable) cost effectiveness and

outcome effectiveness of proposed strategies and interVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00069 Fmt 6659 Sfmt 6603 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
70

ventions, to the extent that data are reasonably available;

(iii) priorities of the communities with HIV disease

for whom the services are intended;

(iv) availability of other governmental and nongovernmental resources to provide HIV-related services

to individuals and families with HIV disease, including the State plan under title XIX of the Social Security Act (relating to the Medicaid program) and the

program under title XXI of such Act (relating to the

program for State children’s health insurance); and

(v) capacity development needs resulting from disparities in the availability of HIV-related services in

historically underserved communities;

ø(B) develop a comprehensive plan for the organization

and delivery of health services described in section 2604

that is compatible with any existing State or local plan regarding the provision of health services to individuals with

HIV disease;¿

(D) develop a comprehensive plan for the organization

and delivery of health and support services described in

section 2604 that—

(i) includes a strategy for identifying individuals

with HIV disease who are not receiving such services

and for informing the individuals of and enabling the

individuals to utilize the services, giving particular attention to eliminating disparities in access and services

among affected subpopulations and historically underserved communities, and including discrete goals, a

timetable, and an appropriate allocation of funds;

(ii) includes a strategy to coordinate the provision of

such services with programs for HIV prevention and

for the prevention and treatment of substance abuse,

including programs that provide comprehensive treatment services for such abuse; and

(iii) is compatible with any State or local plan for the

provision of services to individuals with HIV disease;

ø(C)¿ (E) assess the efficiency of the administrative

mechanism in rapidly allocating funds to the areas of

greatest need within the eligible area, and at the discretion of the planning council, assess the effectiveness, either

directly or through contractual arrangements, of the services offered in meeting the identified needs;

ø(D)¿ (F) participate in the development of the statewide

coordinated statement of need initiated by the State public

health agency responsible for administering grants under

part B; øand¿

ø(E)¿ (G) establish methods for obtaining input on community needs and priorities which may include øpublic

meetings,¿ public meetings (in accordance with paragraph

(7)), conducting focus groups, and convening ad-hoc

panelsø.¿; and

(H) coordinate with Federal grantees that provide HIVrelated services within the eligible area.

* * * * * * *

71

(5) CONFLICTS OF INTEREST.— (A) * * *

* * * * * * *

(C) COMPOSITION OF COUNCIL.—The following applies regarding the membership of a planning council under paragraph (1):

(i) Not less than 33 percent of the council shall be individuals who are receiving HIV-related services pursuant to a grant under section 2601(a), are not officers,

employees, or consultants to any entity that receives

amounts from such a grant, and do not represent any

such entity, and reflect the demographics of the population of individuals with HIV disease as determined

under paragraph (4)(A). For purposes of the preceding

sentence, an individual shall be considered to be receiving such services if the individual is a parent of, or a

caregiver for, a minor child who is receiving such services.

(ii) With respect to membership on the planning

council, clause (i) may not be construed as having any

effect on entities that receive funds from grants under

any of parts B through F but do not receive funds from

grants under section 2601(a), on officers or employees

of such entities, or on individuals who represent such

entities.

* * * * * * *

(7) PUBLIC DELIBERATIONS.—With respect to a planning council under paragraph (1), the following applies:

(A) The council may not be chaired solely by an employee

of the grantee under section 2601(a).

(B) In accordance with criteria established by the Secretary:

(i) The meetings of the council shall be open to the

public and shall be held only after adequate notice to

the public.

(ii) The records, reports, transcripts, minutes, agenda, or other documents which were made available to

or prepared for or by the council shall be available for

public inspection and copying at a single location.

(iii) Detailed minutes of each meeting of the council

shall be kept. The accuracy of all minutes shall be certified to by the chair of the council.

(iv) This subparagraph does not apply to any disclosure of information of a personal nature that would

constitute a clearly unwarranted invasion of personal

privacy, including any disclosure of medical information or personnel matters.

* * * * * * *

(d) PROCESS FOR ESTABLISHING ALLOCATION PRIORITIES.—

Promptly after the date of the submission of the report required in

section 501(b) of the Ryan White CARE Act Amendments of 2000

(relating to the relationship between epidemiological measures and

health care for certain individuals with HIV disease), the Secretary,

72

in consultation with entities that receive amounts from grants under

section 2601(a) or 2611, shall develop epidemiologic measures—

(1) for establishing the number of individuals living with

HIV disease who are not receiving HIV-related health services;

and

(2) for carrying out the duties under subsection (b)(4) and section 2617(b).

(e) TRAINING GUIDANCE AND MATERIALS.—The Secretary shall

provide to each chief elected official receiving a grant under 2601(a)

guidelines and materials for training members of the planning

council under paragraph (1) regarding the duties of the council.

SEC. 2603. TYPE AND DISTRIBUTION OF GRANTS.

(a) GRANTS BASED ON RELATIVE NEED OF AREA.— (1) * * *

(2) EXPEDITED DISTRIBUTION.—Not later than 60 days after

an appropriation becomes available to carry out this part øfor

each of the fiscal years 1996 through 2000¿ for a fiscal year, the Secretary shall, except in the case of waivers granted

under section 2605(c), disburse 50 percent of the amount appropriated under section 2677 for such fiscal year through

grants to eligible areas under section 2601(a), in accordance

with paragraph (3). The Secretary shall reserve an additional

percentage of the amount appropriated under section 2677 for

a fiscal year for grants under part A to make grants to eligible

areas under section 2601(a) in accordance with paragraph (4).

(3) AMOUNT OF GRANT.— (A) * * *

* * * * * * *

(C) ESTIMATE OF LIVING CASES.—The amount determined

in this subparagraph is an amount equal to the product

of—

(i) the number of cases of acquired immune deficiency syndrome in the eligible area during each year

in the most recent 120-month period for which data

are available with respect to all eligible areas, as indicated by the number of such cases reported to and confirmed by the Director of the Centers for Disease Control and Prevention for each year during such period, except that (subject to subparagraph (D)), for grants

made pursuant to this paragraph for fiscal year 2005

and subsequent fiscal years, the cases counted for each

12-month period beginning on or after July 1, 2004,

shall be cases of HIV disease (as reported to and confirmed by such Director) rather than cases of acquired

immune deficiency syndrome; and

(ii) with respect to—

(I) * * *

* * * * * * *

(X) the tenth year during such period, .88.

The yearly percentage described in subparagraph (ii) shall

be updated biennially by the Secretary, after consultation

with the Centers for Disease Control and Prevention, and

shall be reported to the congressional committees of jurisdiction. The first such update shall occur prior to the deVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00072 Fmt 6659 Sfmt 6601 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
73

termination of grant awards under this part for fiscal year

1998. Updates shall as applicable take into account the

counting of cases of HIV disease pursuant to clause (i).

(D) DETERMINATION OF SECRETARY REGARDING DATA ON

HIV CASES.— (i) IN GENERAL.—Not later than July 1, 2004, the

Secretary shall determine whether there is data on

cases of HIV disease from all eligible areas (reported to

and confirmed by the Director of the Centers for Disease Control and Prevention) sufficiently accurate and

reliable for use for purposes of subparagraph (C)(i). In

making such a determination, the Secretary shall take

into consideration the findings of the study under section 501(b) of the Ryan White CARE Act Amendments

of 2000 (relating to the relationship between epidemiological measures and health care for certain individuals with HIV disease), the fiscal impact of the use of

such data, the impact of the use of such data on the

organization and delivery of HIV-related services in eligible areas, and the fiscal impact of not using such

data.

(ii) EFFECT OF ADVERSE DETERMINATION.—If under

clause (i) the Secretary determines that data on cases

of HIV disease is not sufficiently accurate and reliable

for use for purposes of subparagraph (C)(i), then notwithstanding such subparagraph, for any fiscal year

prior to fiscal year 2007 the references in such subparagraph to cases of HIV disease do not have any

legal effect.

(iii) GRANTS AND TECHNICAL ASSISTANCE REGARDING

COUNTING OF HIV CASES.—Of the amounts appropriated under section 2675 for a fiscal year, the Secretary shall reserve amounts to make grants and provide technical assistance to States and eligible areas

with respect to obtaining data on cases of HIV disease

to ensure that data on such cases is available from all

States and eligible areas as soon as is practicable but

not later than the beginning of fiscal year 2007.

ø(D)¿ (E) UNEXPENDED FUNDS.—The Secretary may, in

determining the amount of a grant for a fiscal year under

this paragraph, adjust the grant amount to reflect the

amount of unexpended and uncanceled grant funds remaining at the end of the fiscal year preceding the year for

which the grant determination is to be made. The amount

of any such unexpended funds shall be determined using

the financial status report of the grantee.

ø(4) INCREASE IN GRANT.—With respect to an eligible area

under section 2601(a), the Secretary shall increase the amount

of a grant under paragraph (2) for a fiscal year to ensure that

such eligible area receives not less than—

ø(A) with respect to fiscal year 1996, 100 percent;

ø(B) with respect to fiscal year 1997, 99 percent;

ø(C) with respect to fiscal year 1998, 98 percent;

ø(D) with respect to fiscal year 1999, 96.5 percent; and

ø(E) with respect to fiscal year 2000, 95 percent;

74

of the amount allocated for fiscal year 1995 to such entity

under this subsection.¿

(4) INCREASES IN GRANT.—

(A) IN GENERAL.—For each fiscal year in a protection period for an eligible area, the Secretary shall increase the

amount of the grant made pursuant to paragraph (2) for

the area to ensure that—

(i) for the first fiscal year in the protection period,

the grant is not less than 98 percent of the amount of

the grant made for the eligible area pursuant to such

paragraph for the base year for the protection period;

(ii) for any second fiscal year in such period, the

grant is not less than 95.7 percent of the amount of

such base year grant;

(iii) for any third fiscal year in such period, the

grant is not less than 91.1 percent of the amount of the

base year grant;

(iv) for any fourth fiscal year in such period, the

grant is not less than 84.2 percent of the amount of the

base year grant; and

(v) for any fifth or subsequent fiscal year in such period, the grant is not less than 75 percent of the

amount of the base year grant.

(B) BASE YEAR; PROTECTION PERIOD.—With respect to

grants made pursuant to paragraph (2) for an eligible area:

(i) The base year for a protection period is the fiscal

year preceding the trigger grant-reduction year.

(ii) The first trigger grant-reduction year is the first

fiscal year (after fiscal year 2000) for which the grant

for the area is less than the grant for the area for the

preceding fiscal year.

(iii) A protection period begins with the trigger

grant-reduction year and continues until the beginning

of the first fiscal year for which the amount of the

grant for the area equals or exceeds the amount of the

grant for the base year for the period.

(iv) Any subsequent trigger grant-reduction year is

the first fiscal year, after the end of the preceding protection period, for which the amount of the grant is less

than the amount of the grant for the preceding fiscal

year.

(b) SUPPLEMENTAL GRANTS.—

(1) IN GENERAL.—Not later than 150 days after the date on

which appropriations are made under section 2677 for a fiscal

year, the Secretary shall disburse the remainder of amounts

not disbursed under section 2603(a)(2) for such fiscal year for

the purpose of making grants under section 2601(a) to eligible

areas whose application under section 2605(b)—

(A) * * *

* * * * * * *

(E) demonstrates that resources will be allocated in accordance with the local demographic incidence of AIDS inVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00074 Fmt 6659 Sfmt 6601 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
75

cluding appropriate allocations for services for infants,

children, youth, women, and families with HIV disease;

* * * * * * *

(2) øDEFINITION¿ AMOUNT OF GRANT.—

(A) IN GENERAL.—The amount of each grant made for

purposes of this subsection shall be determined by the Secretary based on a weighting of factors under paragraph (1),

with severe need under subparagraph (B) of such paragraph counting one-third.

ø(A)¿ (B) SEVERE NEED.—In determining severe need in

accordance with paragraph (1)(B), the Secretary shall consider the ability of the qualified applicant to expend funds

efficiently and the impact of relevant factors on the cost

and complexity of delivering health care and support services to individuals with HIV disease in the eligible area,

including factors such as—

(i) sexually transmitted diseases, substance abuse,

tuberculosis, severe mental illness, or other comorbid

factors determined relevant by the Secretary;

(ii) new or growing subpopulations of individuals

with HIV disease; øand¿

(iii) homelessnessø.¿;

(iv) the current prevalence of HIV disease;

(v) an increasing need for HIV-related services, including relative rates of increase in the number of

cases of HIV disease; and

(vi) unmet need for such services, as determined

under section 2602(b)(4).

ø(B)¿ (C) PREVALENCE.—In determining the impact of

the factors described in subparagraph ø(A)¿ (B), the Secretary shall, to the extent practicable, use national, quantitative incidence data that are available for each eligible

area. Not later than ø2 years after the date of enactment

of this paragraph¿ 18 months after the date of the enactment of the Ryan White CARE Act Amendments of 2000,

the Secretary shall develop a mechanism to utilize such

data. Such a mechanism shall be modified to reflect the

findings of the study under section 501(b) of the Ryan

White CARE Act Amendments of 2000 (relating to the relationship between epidemiological measures and health care

for certain individuals with HIV disease). In the absence

of such data, the Secretary may consider a detailed description and qualitative analysis of severe need, as determined under subparagraph ø(A)¿ (B), including any local

prevalence data gathered and analyzed by the eligible

area.

ø(C)¿ (D) PRIORITY.—Subsequent to the development of

the quantitative mechanism described in subparagraph

ø(B)¿ (C), the Secretary shall phase in, over a 3-year period beginning in fiscal year 1998, the use of such a mechanism to determine the severe need of an eligible area

compared to other eligible areas and to determine, in part,

the amount of supplemental funds awarded to the eligible

area under this part.

76

ø(4) AMOUNT OF GRANT.—The amount of each grant made for

purposes of this subsection shall be determined by the Secretary based on the application submitted by the eligible area

under section 2605(b).¿

ø(5)¿ (4) FAILURE TO SUBMIT.— (A) * * *

* * * * * * *

SEC. 2604. USE OF AMOUNTS.

(a) * * *

(b) PRIMARY PURPOSES.— (1) IN GENERAL.—The chief elected official shall use amounts

received under a grant under section 2601 to provide direct financial assistance to entities described in paragraph (2) for the

purpose of delivering or enhancing øHIVrelated—¿ HIV-related services, as follows:

(A) øoutpatient and ambulatory health and support services, including case management, substance abuse treatment and¿ Outpatient and ambulatory health services, including substance abuse treatment, mental health treatment, and comprehensive treatment services, which shall

include treatment education and prophylactic treatment

for opportunistic infections, for individuals and families

with HIV diseaseø; and¿. (B) Outpatient and ambulatory support services (including case management), to the extent that such services facilitate, support, or sustain the delivery, or benefits of

health services for individuals and families with HIV disease.

ø(B) inpatient case management¿ (C) Inpatient case

management services that prevent unnecessary hospitalization or that expedite discharge, as medically appropriate, from inpatient facilities.

(D) Outreach activities that are intended to identify individuals with HIV disease who are not receiving HIV-related

services, and that are—

(i) necessary to implement the strategy under section

2602(b)(4)(D), including activities facilitating the access of such individuals to HIV-related primary care

services at entities described in paragraph (3);

(ii) conducted in a manner consistent with the requirements under sections 2605(a)(3) and 2651(b)(2);

and

(iii) supplement, and do not supplant, such activities

that are carried out with amounts appropriated under

section 317.

* * * * * * *

(3) EARLY INTERVENTION SERVICES.—

(A) IN GENERAL.—The purposes for which a grant under

section 2601 may be used include providing to individuals

with HIV disease early intervention services described in

section 2651(b)(2) (including referrals under subparagraph

(C) of such section), subject to subparagraph (B). The entities through which such services may be provided under the

grant include public health departments, emergency rooms,

77

substance abuse and mental health treatment programs,

detoxification centers, detention facilities, clinics regarding

sexually transmitted diseases, homeless shelters, HIV disease counseling and testing sites, health care points of entry

specified by States or eligible areas, federally qualified

health centers, and entities described in section 2652(a).

(B) CONDITIONS.—With respect to an entity that proposes

to provide early intervention services under subparagraph

(A), such subparagraph applies only if the entity demonstrates to the satisfaction of the chief elected official for

the eligible area involved that—

(i) Federal, State, or local funds are otherwise inadequate for the early intervention services the entity proposes to provide; and

(ii) the entity will expend funds pursuant to such

subparagraph to supplement and not supplant other

funds available to the entity for the provision of early

intervention services for the fiscal year involved.

ø(3)¿ (4) PRIORITY FOR WOMEN, INFANTS AND CHILDREN.—For

the purpose of providing health and support services to infants,

children, youth, and women with HIV disease, including treatment measures to prevent the perinatal transmission of HIV,

the chief elected official of an eligible area, in accordance with

the established priorities of the planning council, shall use,

from the grants made for the area under section 2601(a) for a

fiscal year, not less than the percentage constituted by the

ratio of the population in such area of infants, children, youth,

and women with acquired immune deficiency syndrome to the

general population in such area of individuals with such syndrome.

(c) QUALITY MANAGEMENT.—

(1) REQUIREMENT.—The chief elected official of an eligible

area that receives a grant under this part shall provide for the

establishment of a quality management program to assess the

extent to which HIV health services provided to patients under

the grant are consistent with the most recent Public Health

Service guidelines for the treatment of HIV disease and related

opportunistic infection, and as applicable, to develop strategies

for ensuring that such services are consistent with the guidelines.

(2) USE OF FUNDS.—From amounts received under a grant

awarded under this part for a fiscal year, the chief elected official of an eligible area may (in addition to amounts to which

subsection (f)(1) applies) use for activities associated with the

quality management program required in paragraph (1) not

more than the lesser of—

(A) 5 percent of amounts received under the grant; or

(B) $3,000,000.

ø(c)¿ (d) LIMITED EXPENDITURES FOR PERSONNEL NEEDS.—

(1) * * *

* * * * * * *

ø(d)¿ (e) REQUIREMENT OF STATUS AS MEDICAID PROVIDER.—

(1) * * *

ø(e)¿ (f) ADMINISTRATION.—

78

(1) IN GENERAL.—The chief executive officer of an eligible

area shall not use in excess of 5 percent of amounts received

under a grant awarded under this part for administration. In

the case of entities and subcontractors to which such officer allocates amounts received by the officer under the grant, the officer shall ensure that, of the aggregate amount so allocated,

the total of the expenditures by such entities for administrative

expenses does not exceed 10 percent (without regard to whether particular entities expend more than 10 percent for such expenses).

* * * * * * *

ø(f)¿ (g) CONSTRUCTION.—A State may not use amounts received

under a grant awarded under this part to purchase or improve

land, or to purchase, construct, or permanently improve (other than

minor remodeling) any building or other facility, or to make cash

payments to intended recipients of services.

SEC. 2605. APPLICATION.

(a) IN GENERAL.—To be eligible to receive a grant under section

2601, an eligible area shall prepare and submit to the Secretary an

application, in accordance with subsection (c) regarding a single application and grant award, at such time, in such form, and containing such information as the Secretary shall require, including

assurances adequate to ensure—

(1) * * *

* * * * * * *

(3) that entities within the eligible area that receive funds

under a grant under section 2601(a) will maintain relationships with appropriate entities in the area, including entities

described in section 2604(b)(3);

ø(3)¿ (4) that entities within the eligible area that will receive funds under a grant provided under section 2601(a) shall

participate in an established HIV community-based continuum

of care if such continuum exists within the eligible area;

ø(4)¿ (5) that funds received under a grant awarded under

this part will not be utilized to make payments for any item

or service to the extent that payment has been made, or can

reasonably be expected to be made, with respect to that item

or service—

(A) under any State compensation program, under an insurance policy, or under any Federal or State health benefits program; or

(B) by an entity that provides health services on a prepaid basis;

ø(5)¿ (6) to the maximum extent practicable, that—

(A) HIV health care and support services provided with

assistance made available under this part will be provided

without regard—

(i) * * *

* * * * * * *

ø(6)¿ (7) that the applicant has participated, or will agree to

participate, in the statewide coordinated statement of need

process where it has been initiated by the State public health

agency responsible for administering grants under part B, and

79

ensure that the services provided under the comprehensive

plan are consistent with the statewide coordinated statement

of need.

* * * * * * *

PART B—CARE GRANT PROGRAM

Subpart I—General Grant Provisions

SEC. 2611. GRANTS.

(a) * * *

(b) PRIORITY FOR WOMEN, INFANTS AND CHILDREN.—For the purpose of providing health and support services to infants, children,

youth, and women with HIV disease, including treatment measures

to prevent the perinatal transmission of HIV, a State shall use, of

the funds allocated under this part to the State for a fiscal year,

not less than the percentage constituted by the ratio of the population in the State of infants, children, youth, and women with acquired immune deficiency syndrome to the general population in

the State of individuals with such syndrome.

* * * * * * *

SEC. 2612. GENERAL USE OF GRANTS.

(a) IN GENERAL.—A State may use amounts provided under

grants made under this part—

(1) * * *

(b) SUPPORT SERVICES; OUTREACH.—The purposes for which a

grant under this part may be used include delivering or enhancing

the following:

(1) Support services under section 2611(a) (including case

management) to the extent that such services facilitate, support,

or sustain the delivery, or benefits of health services for individuals and families with HIV disease.

(2) Outreach activities that are intended to identify individuals with HIV disease who are not receiving HIV-related services, and that are—

(A) necessary to implement the strategy under section

2617(b)(4)(B);

(B) conducted in a manner consistent with the requirement under section 2617(b)(6)(G); and

(C) supplement, and do not supplant, such activities that

are carried out with amounts appropriated under section

317.

(c) EARLY INTERVENTION SERVICES.—

(1) IN GENERAL.—The purposes for which a grant under this

part may be used include providing to individuals with HIV

disease early intervention services described in section

2651(b)(2) (including referrals under subparagraph (C) of such

section), subject to paragraph (2). The entities through which

such services may be provided under the grant include public

health departments, emergency rooms, substance abuse and

mental health treatment programs, detoxification centers, detention facilities, clinics regarding sexually transmitted diseases,

homeless shelters, HIV disease counseling and testing sites,

80

health care points of entry specified by States or eligible areas,

federally qualified health centers, and entities described in section 2652(a).

(2) CONDITIONS.—With respect to an entity that proposes to

provide early intervention services under paragraph (1), such

paragraph applies only if the entity demonstrates to the satisfaction of the State involved that—

(A) Federal, State, or local funds are otherwise inadequate for the early intervention services the entity proposes

to provide; and

(B) the entity will expend funds pursuant to such paragraph to supplement and not supplant other funds available to the entity for the provision of early intervention

services for the fiscal year involved.

(d) QUALITY MANAGEMENT.— (1) REQUIREMENT.—Each State that receives a grant under

this part shall provide for the establishment of a quality management program to assess the extent to which HIV health services provided to patients under the grant are consistent with the

most recent Public Health Service guidelines for the treatment

of HIV disease and related opportunistic infection, and as applicable, to develop strategies for ensuring that such services are

consistent with the guidelines.

(2) USE OF FUNDS.—From amounts received under a grant

awarded under this part for a fiscal year, the State may (in addition to amounts to which section 2618(c)(5) applies) use for

activities associated with the quality management program required in paragraph (1) not more than the lesser of—

(A) 5 percent of amounts received under the grant; or

(B) $3,000,000.

SEC. 2613. GRANTS TO ESTABLISH HIV CARE CONSORTIA.

(a) * * *

(b) ASSURANCES.— (1) REQUIREMENT.—To receive assistance from a State under

subsection (a), an applicant consortium shall provide the State

with assurances that—

(A) within any locality in which such consortium is to

operate, the populations and subpopulations of individuals

and families with HIV disease have been identified by the

consortium, particularly those experiencing disparities in

access and services and those who reside in historically underserved communities;

(B) the service plan established under subsection (c)(2)

by such consortium is consistent with the comprehensive

plan under 2617(b)(4) and addresses the special care and

service needs of the populations and subpopulations identified under subparagraph (A); and

* * * * * * *

(c) APPLICATION.—

(1) IN GENERAL.—To receive assistance from the State under

subsection (a), a consortium shall prepare and submit to the

State, an application that—

(A) * * *

* * * * * * *

81

(D) demonstrates that the consortium has created a

mechanism to evaluate periodically—

(i) * * *

(ii) the cost-effectiveness of the mechanisms employed by the consortium to deliver comprehensive

care; øand¿

(E) demonstrates that the consortium will report to the

State the results of the evaluations described in subparagraph (D) and shall make available to the State or the Secretary, on request, such data and information on the program methodology that may be required to perform an

independent evaluationø.¿; and

(F) demonstrates that adequate planning occurred to address disparities in access and services and historically underserved communities.

(2) CONSULTATION.—In establishing the plan required under

paragraph (1)(B), the consortium shall consult with—

(A) * * *

(B) not less than one community-based organization that

is organized solely for the purpose of providing HIV-related support services to individuals with HIV disease;

øand¿

(C) grantees under section 2671, or, if none are operating in the area, representatives in the area of organizations with a history of serving children, youth, women, and

families living with HIVø.¿; and

(D) entities described in section 2602(b)(2).

The organization to be consulted under subparagraph (B) shall

be at the discretion of the applicant consortium.

* * * * * * *

SEC. 2616. PROVISION OF TREATMENTS.

(a) * * *

* * * * * * *

(e) USE OF HEALTH INSURANCE AND PLANS.—In carrying out subsection (a), a State may expend a grant under this part to provide

the therapeutics described in such subsection by paying on behalf of

individuals with HIV disease the costs of purchasing or maintaining health insurance or plans whose coverage includes a full range

of such therapeutics and appropriate primary care services.

SEC. 2617. STATE APPLICATION.

(a) * * *

(b) DESCRIPTION OF INTENDED USES AND AGREEMENTS.—The application submitted under subsection (a) shall contain—

(1) * * *

(2) a determination of the size and demographics of the population of individuals with HIV disease in the State;

(3) a determination of the needs of such population, with particular attention to—

(A) individuals with HIV disease who are not receiving

HIV-related services; and

(B) disparities in access and services among affected subpopulations and historically underserved communities;

82

ø(2)¿ (4) a øcomprehensive plan for the organization¿ comprehensive plan that describes the organization and delivery of

HIV health care and support services to be funded with assistance received under this part that shall include a description

of the purposes for which the State intends to use such

assistanceø, including—¿, and that—

(A) establishes priorities for the allocation of funds within the State based on—

(i) size and demographics of the population of individuals with HIV disease (as determined under paragraph (2)) and the needs of such population (as determined under paragraph (3));

(ii) availability of other governmental and nongovernmental resources to provide HIV-related services

to individuals and families with HIV disease;

(iii) capacity development needs resulting from disparities in the availability of HIV-related services in

historically underserved communities and rural communities; and

(iv) the efficiency of the administrative mechanism of

the State for rapidly allocating funds to the areas of

greatest need within the State;

(B) includes a strategy for identifying individuals with

HIV disease who are not receiving such services and for informing the individuals of and enabling the individuals to

utilize the services, giving particular attention to eliminating disparities in access and services among affected

subpopulations and historically underserved communities,

and including discrete goals, a timetable, and an appropriate allocation of funds;

(C) includes a strategy to coordinate the provision of such

services with programs for HIV prevention and for the prevention and treatment of substance abuse, including programs that provide comprehensive treatment services for

such abuse;

ø(A)¿ (D) describes the services and activities to be provided and an explanation of the manner in which the elements of the program to be implemented by the State with

such assistance will maximize the quality of health and

support services available to individuals with HIV disease

throughout the State;

ø(B)¿ (E) provides a description of the manner in which

services funded with assistance provided under this part

will be coordinated with other available related services for

individuals with HIV disease; and

ø(C)¿ (F) provides a description of how the allocation

and utilization of resources are consistent with the statewide coordinated statement of need (including traditionally

underserved populations and subpopulations) developed in

partnership with other grantees in the State that receive

funding under this title; and

ø(3)¿ (5) an assurance that the public health agency administering the grant for the State will periodically convene a

meeting of individuals with HIV disease, representatives of

grantees under each part under this title, providers, and public

83

agency representatives for the purpose of developing a statewide coordinated statement of need; and

ø(4)¿ (6) an assurance by the State that—

ø(A) the public health agency that is administering the

grant for the State will conduct public hearings concerning

the proposed use and distribution of the assistance to be

received under this part;¿

(A) the public health agency that is administering the

grant for the State engages in a public advisory planning

process, including public hearings, that includes the participants under paragraph (5), and entities described in

section 2602(b)(2), in developing the comprehensive plan

under paragraph (4) and commenting on the implementation of such plan;

* * * * * * *

(E) the State will maintain HIV-related activities at a

level that is equal to not less than the level of such expenditures by the State for the 1-year period preceding the

fiscal year for which the State is applying to receive a

grant under this part; øand¿

(F) the State will ensure that grant funds are not utilized to make payments for any item or service to the extent that payment has been made, or can reasonably be expected to be made, with respect to that item or service—

(i) * * *

(ii) by an entity that provides health services on a

prepaid basisø.¿; and

(G) entities within areas in which activities under the

grant are carried out will maintain relationships with appropriate entities in the area, including entities described

in section 2612(c);

* * * * * * *

SEC. 2618. DISTRIBUTION OF FUNDS.

(b) AMOUNT OF GRANT TO STATE.— (1) MINIMUM ALLOTMENT.—Subject to the extent of amounts

made available under section 2677, the amount of a grant to

be made under this part for—

(A) each of the several States and the District of Columbia for a fiscal year shall be the greater of—

(i)(I) with respect to a State or District that has less

than 90 living cases of acquired immune deficiency

syndrome, as determined under paragraph (2)(D),

ø$100,000¿ $200,000; or

(II) with respect to a State or District that has 90

or more living cases of acquired immune deficiency

syndrome, as determined under paragraph (2)(D),

ø$250,000¿ $500,000;

(ii) an amount determined under paragraph (2) and

then, as applicable, increased under paragraph (2)(H);

and

(B) each territory of the United States, as defined in

paragraph (3), shall be the greater of $50,000 or an amount

determined under paragraph (2).

(2) DETERMINATION.—

84

(A) FORMULA.—The amount referred to in paragraph

(1)(A)(ii) for a State and paragraph (1)(B) for a territory of

the United States shall be the product of—

(i) an amount equal to the amount appropriated

under section 2677 for the fiscal year involved for

grants under part B, subject to øsubparagraph (H)¿

subparagraphs (H) and (I); and

* * * * * * *

(D) ESTIMATE OF LIVING CASES.—The amount determined

in this subparagraph is an amount equal to the product

of—

(i) the number of cases of acquired immune deficiency syndrome in the State or territory during each

year in the most recent 120-month period for which

data are available with respect to all States and territories, as indicated by the number of such cases reported to and confirmed by the Director of the Centers

for Disease Control and Prevention for each year during such period, except that (subject to subparagraph

(E)), for grants made pursuant to this paragraph for

fiscal year 2005 and subsequent fiscal years, the cases

counted for each 12-month period beginning on or after

July 1, 2004, shall be cases of HIV disease (as reported

to and confirmed by such Director) rather than cases

of acquired immune deficiency syndrome; and

(E) DETERMINATION OF SECRETARY REGARDING DATA ON

HIV CASES.—If under 2603(a)(3)(D)(i) the Secretary determines that data on cases of HIV disease is not sufficiently

accurate and reliable, then notwithstanding subparagraph

(D) of this paragraph, for any fiscal year prior to fiscal year

2007 the references in such subparagraph to cases of HIV

disease do not have any legal effect.

ø(E)¿ (F) PUERTO RICO, VIRGIN ISLANDS, GUAM.—For purposes of subparagraph (D), the cost index for Puerto Rico,

the Virgin Islands, and Guam shall be 1.0.

ø(F)¿ (G) UNEXPENDED FUNDS.—The Secretary may, in

determining the amount of a grant for a fiscal year under

this subsection, adjust the grant amount to reflect the

amount of unexpended and uncanceled grant funds remaining at the end of the fiscal year preceding the year for

which the grant determination is to be made. The amount

of any such unexpended funds shall be determined using

the financial status report of the grantee.

ø(G) LIMITATION.— ø(i) IN GENERAL.—The Secretary shall ensure that

the amount of a grant awarded to a State or territory

for a fiscal year under this part is equal to not less

than—

ø(I) with respect to fiscal year 1996, 100 percent;

ø(II) with respect to fiscal year 1997, 99 percent;

ø(III) with respect to fiscal year 1998, 98 percent;

ø(IV) with respect to fiscal year 1999, 96.5 percent; and

85

ø(V) with respect to fiscal year 2000, 95 percent;

of the amount such State or territory received for fiscal year 1995 under this part. In administering this

subparagraph, the Secretary shall, with respect to

States that will receive grants in amounts that exceed

the amounts that such States received under this part

in fiscal year 1995, proportionally reduce such

amounts to ensure compliance with this subparagraph.

In making such reductions, the Secretary shall ensure

that no such State receives less than that State received for fiscal year 1995.

ø(ii) RATABLE REDUCTION.—If the amount appropriated under section 2677 and available for allocation

under this part is less than the amount appropriated

and available under this part for fiscal year 1995, the

limitation contained in clause (i) shall be reduced by

a percentage equal to the percentage of the reduction

in such amounts appropriated and available.¿

(H) LIMITATION.— (i) IN GENERAL.—The Secretary shall ensure that the

amount of a grant awarded to a State or territory

under section 2611 for a fiscal year is not less than—

(I) with respect to fiscal year 2001, 99 percent;

(II) with respect to fiscal year 2002, 98 percent;

(III) with respect to fiscal year 2003, 97 percent;

(IV) with respect to fiscal year 2004, 96 percent;

and

(V) with respect to fiscal year 2005, 95 percent;

of the amount such State or territory received for fiscal

year 2000 under such section. In administering this

subparagraph, the Secretary shall, with respect to

States or territories that will under such section receive

grants in amounts that exceed the amounts that such

States received under such section for fiscal year 2000,

proportionally reduce such amounts to ensure compliance with this subparagraph. In making such reductions, the Secretary shall ensure that no such State receives less than that State received for fiscal year 2000.

(ii) RATABLE REDUCTION.—If the amount appropriated under section 2677 for a fiscal year and available for grants under section 2611 is less than the

amount appropriated and available under such section

for fiscal year 2000, the limitation contained in clause

(i) shall be reduced by a percentage equal to the percentage of the reduction in such amounts appropriated

and available.

ø(H) APPROPRIATIONS FOR TREATMENT DRUG PROGRAM.—

With respect to¿

(I) APPROPRIATIONS FOR TREATMENT DRUG PROGRAM.—

(i) FORMULA GRANTS.—With respect to the fiscal year

involved, if under section 2677 an appropriations Act

provides an amount exclusively for carrying out section 2616, the portion of such amount allocated to a

State shall be the product of—

ø(i)¿ (I) ø100¿ 98 percent of such amount; and

86

ø(ii)¿ (II) the percentage constituted by the ratio of

the State distribution factor for the State (as determined under subparagraph (B)) to the sum of the

State distribution factors for all States.

(ii) SUPPLEMENTAL TREATMENT DRUG GRANTS.— (I) IN GENERAL.—With respect to the fiscal year

involved, if under section 2677 an appropriations

Act provides an amount exclusively for carrying

out section 2616, and such amount is not less than

the amount so provided for the preceding fiscal

year, the Secretary shall reserve 2 percent of such

amount for making grants to States whose population of individuals with HIV disease has, as determined by the Secretary, a need for quantities of

therapeutics described in section 2616(a) greater

than the quantities available pursuant to clause

(i). Such a grant is available for purposes of obtaining such therapeutics. The Secretary shall

carry out this clause as a program of discretionary

grants, and not as a program of formula grants.

(II) DISTRIBUTION OF GRANTS.—The Secretary

shall disburse all amounts under grants under

subclause (I) for a fiscal year not later than 240

days after the date on which the amount referred

to in such subclause with respect to section 2616

becomes available.

(III) REQUIREMENT OF MATCHING FUNDS.—A

condition for receiving a grant under subclause (I)

is that the State agree to make available (directly

or through donations from public or private entities) non-Federal contributions toward the costs of

obtaining the therapeutics involved in an amount

that is not less than 25 percent of such costs (determined in the same manner as under

2617(d)(2)(A)).

* * * * * * *

(3) DEFINITIONS.—As used in this subsection—

(A) * * *

(B) the term ‘‘territory of the United States’’ means,

American Samoa, the Commonwealth of the Northern

Mariana Islands, øand the Republic of the Marshall Islands¿ the Republic of the Marshall Islands, the Federated

States of Micronesia, and the Republic of Palau, and only

for purposes of paragraph (1) the Commonwealth of Puerto

Rico.

* * * * * * *

øSEC. 2621. COORDINATION.

øThe Secretary shall ensure that the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration coordinate the planning and implementation of Federal

HIV programs in order to facilitate the local development of a complete continuum of HIV-related services for individuals with HIV

disease and those at risk of such disease. Not later than October

87

1, 1996, and biennially thereafter, the Secretary shall submit to the

appropriate committees of the Congress a report concerning coordination efforts under this title at the Federal, State, and local levels,

including a statement of whether and to what extent there exist

Federal barriers to integrating HIV-related programs.¿

SEC. 2621. SUPPLEMENTAL GRANTS.

(a) IN GENERAL.—From amounts available pursuant to subsection

(d) for a fiscal year, the Secretary shall make grants to States that

meet the conditions to receive grants under section 2611, and that

have one or more eligible communities, for the purpose of providing

in such communities comprehensive services of the type described in

section 2612(a) to supplement the development and care activities,

primary care, and support services otherwise provided in such communities by the State under a grant under section 2611.

(b) ELIGIBLE COMMUNITY.—For purposes of this section, the term

‘‘eligible community’’ means a geographic area that—

(1) is not within any eligible area as defined in section 2607;

and

(2) has a severe need for supplemental financial assistance to

combat the HIV epidemic, according to criteria developed by the

Secretary in consultation with the States, including evidence of

underserved or rural areas or both.

(c) APPLICATION.—A grant under subsection (a) may be made to

a State if the State submits to the Secretary, as part of the State

application submitted under section 2617, such information as required to apply for funds under this section as determined by the

Secretary in consultation with the States.

(d) FUNDING.—

(1) IN GENERAL.—For the purpose of making grants under

subsection (a) for a fiscal year, the Secretary shall reserve 50

percent of the amount specified in paragraph (2).

(2) INCREASES IN PART B FUNDING.—

(A) IN GENERAL.—For purposes of paragraph (1), the

amount specified in this paragraph is the amount by which

the amount appropriated under section 2677 for the fiscal

year involved and available for carrying out part B is an

increase over the amount so appropriated and available for

the preceding fiscal year, subject to subparagraphs (B) and

(C).

(B) INITIAL ALLOCATION YEAR.—The allocation under

paragraph (1) shall not be made until the first fiscal year

for which the amount appropriated under section 2677 for

the fiscal year involved and available for carrying out part

B is an increase of not less than $20,000,000 over the

amount so appropriated and available for fiscal year 2000,

subject to subparagraph (C).

(C) EXCLUSION REGARDING SEPARATE TREATMENT DRUG

GRANTS.—Each determination under subparagraph (A) or

(B) of the amount appropriated under section 2677 for a

fiscal year and available for carrying out part B shall be

made without regard to any amount to which section

2618(b)(2)(I)(i) applies.

* * * * * * *

88

Subpart II—Provisions Concerning Pregnancy

and Perinatal Transmission of HIV

SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN.

(a) * * *

* * * * * * *

(c) ADDITIONAL FUNDS REGARDING WOMEN AND INFANTS.— (1) IN GENERAL.—If a State provides the certification required in subsection (a) and is receiving funds under part B for

a fiscal year, the Secretary may (from the amounts available

pursuant to paragraph (2)) make a grant to the State for the

fiscal year for the following purposes:

(A) * * *

* * * * * * *

(F) Making available to pregnant women with HIV disease, and to the infants of women with such disease, treatment services for such disease in accordance with applicable recommendations of the Secretary.

ø(2) FUNDING.—For purposes of carrying out this subsection, there are authorized to be appropriated $10,000,000 for each of

the fiscal years 1996 through 2000. Amounts made available

under section 2677 for carrying out this part are not available

for carrying out this section unless otherwise authorized.¿

(2) FUNDING.— (A) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this subsection, there are authorized to

be appropriated $30,000,000 for each of the fiscal years

2001 through 2005. Amounts made available under section

2677 for carrying out this part are not available for carrying out this section unless otherwise authorized.

(B) ALLOCATIONS FOR CERTAIN STATES.— (i) IN GENERAL.—Of the amounts appropriated under

subparagraph (A) for a fiscal year in excess of

$10,000,000, the Secretary shall reserve the applicable

percentage under clause (ii) for making grants under

paragraph (1) to States that under law (including

under regulations or the discretion of State officials)

have—

(I) a requirement that all newborn infants born

in the State be tested for HIV disease; or

(II) a requirement that newborn infants born in

the State be tested for HIV disease in circumstances in which the attending obstetrician for

the birth does not know the HIV status of the

mother of the infant.

(ii) APPLICABLE PERCENTAGE.—For purposes of

clause (i), the applicable amount for a fiscal year is as

follows:

(I) For fiscal year 2001, 25 percent.

(II) For fiscal year 2002, 50 percent.

(III) For fiscal year 2003, 50 percent.

(IV) For fiscal year 2004, 75 percent.

(V) For fiscal year 2005, 75 percent.

89

(C) CERTAIN PROVISIONS.—With respect to grants under

paragraph (1) that are made with amounts reserved under

subparagraph (B) of this paragraph:

(i) Such a grant may not be made in an amount ex- ceeding $4,000,000.

(ii) If pursuant to clause (i) or pursuant to an insufficient number of qualifying applications for such

grants (or both), the full amount reserved under subparagraph (B) for a fiscal year is not obligated, the requirement under such subparagraph to reserve

amounts ceases to apply.

* * * * * * *

(4) MAINTENANCE OF EFFORT.—A condition for the receipt of

a grant under paragraph (1) is that the State involved agree

that the grant will be used to supplement and not supplant

other funds available to the State to carry out the purposes of

the grant.

* * * * * * *

SEC. 2626. PERINATAL TRANSMISSION OF HIV DISEASE; CONTINGENT

REQUIREMENT REGARDING STATE GRANTS UNDER THIS

PART.

(a) * * *

* * * * * * *

ø(d) DETERMINATION BY SECRETARY.—Not later than 180 days

after the expiration of the 18-month period beginning on the date

on which the system is implemented under subsection (c), the Secretary shall publish in the Federal Register a determination of

whether it has become a routine practice in the provision of health

care in the United States to carry out each of the activities described in paragraphs (1) through (4) of section 2627. In making

the determination, the Secretary shall consult with the States and

with other public or private entities that have knowledge or expertise relevant to the determination.

ø(e) CONTINGENT APPLICABILITY.—

ø(1) IN GENERAL.—If the determination published in the Federal Register under subsection (d) is that (for purposes of such

subsection) the activities involved have become routine practices, paragraph (2) shall apply on and after the expiration of

the 18-month period beginning on the date on which the determination is so published.

ø(2) REQUIREMENT.—Subject to subsection (f), the Secretary

shall not make a grant under part B to a State unless the

State meets not less than one of the following requirements:

ø(A) A 50 percent reduction (or a comparable measure

for States with less than 10 cases) in the rate of new cases

of AIDS (recognizing that AIDS is a suboptimal proxy for

tracking HIV in infants and was selected because such

data is universally available) as a result of perinatal transmission as compared to the rate of such cases reported in

1993 (a State may use HIV data if such data is available).

ø(B) At least 95 percent of women in the State who have

received at least two prenatal visits (consultations) prior to

34 weeks gestation with a health care provider or provider

90

group have been tested for the human immunodeficiency

virus.

ø(C) The State has in effect, in statute or through regulations, the requirements specified in paragraphs (1)

through (5) of section 2627.

ø(f) LIMITATION REGARDING AVAILABILITY OF FUNDS.—With respect to an activity described in any of paragraphs (1) through (4)

of section 2627, the requirements established by a State under this

section apply for purposes of this section only to the extent that the

following sources of funds are available for carrying out the activity:

ø(1) Federal funds provided to the State in grants under part

B or under section 2625, or through other Federal sources

under which payments for routine HIV testing, counseling or

treatment are an eligible use.

ø(2) Funds that the State or private entities have elected to

provide, including through entering into contracts under which

health benefits are provided. This section does not require any

entity to expend non-Federal funds.

øSEC. 2627. TESTING OF PREGNANT WOMEN AND NEWBORN INFANTS.

øAn activity or requirement described in this section is any of

the following:

ø(1) In the case of newborn infants who are born in the State

and whose biological mothers have not undergone prenatal

testing for HIV disease, that each such infant undergo testing

for such disease.

ø(2) That the results of such testing of a newborn infant be

promptly disclosed in accordance with the following, as applicable to the infant involved:

ø(A) To the biological mother of the infant (without regard to whether she is the legal guardian of the infant).

ø(B) If the State is the legal guardian of the infant:

ø(i) To the appropriate official of the State agency

with responsibility for the care of the infant.

ø(ii) To the appropriate official of each authorized

agency providing assistance in the placement of the infant.

ø(iii) If the authorized agency is giving significant

consideration to approving an individual as a foster

parent of the infant, to the prospective foster parent.

ø(iv) If the authorized agency is giving significant

consideration to approving an individual as an adoptive parent of the infant, to the prospective adoptive

parent.

ø(C) If neither the biological mother nor the State is the

legal guardian of the infant, to another legal guardian of

the infant.

ø(D) To the child’s health care provider.

ø(3) That, in the case of prenatal testing for HIV disease

that is conducted in the State, the results of such testing be

promptly disclosed to the pregnant woman involved.

ø(4) That, in disclosing the test results to an individual

under paragraph (2) or (3), appropriate counseling on the

human immunodeficiency virus be made available to the indiVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00090 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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vidual (except in the case of a disclosure to an official of a

State or an authorized agency).

ø(5) With respect to State insurance laws, that such laws

require—

ø(A) that, if health insurance is in effect for an individual, the insurer involved may not (without the consent

of the individual) discontinue the insurance, or alter the

terms of the insurance (except as provided in subparagraph (C)), solely on the basis that the individual is infected with HIV disease or solely on the basis that the individual has been tested for the disease or its manifestation;

ø(B) that subparagraph (A) does not apply to an individual who, in applying for the health insurance involved,

knowingly misrepresented the HIV status of the individual; and

ø(C) that subparagraph (A) does not apply to any reasonable alteration in the terms of health insurance for an

individual with HIV disease that would have been made if

the individual had a serious disease other than HIV disease.

For purposes of this subparagraph, a statute or regulation

shall be deemed to regulate insurance for purposes of this

paragraph only to the extent that such statute or regulation is

treated as regulating insurance for purposes of section

514(b)(2) of the Employee Retirement Income Security Act of

1974.¿

* * * * * * *

SEC. 2630. RECOMMENDATIONS FOR REDUCING INCIDENCE OF

PERINATAL TRANSMISSION.

(a) STUDY BY INSTITUTE OF MEDICINE.—

(1) IN GENERAL.—The Secretary shall request the Institute of

Medicine to enter into an agreement with the Secretary under

which such Institute conducts a study to provide the following:

(A) For the most recent fiscal year for which the information is available, a determination of the number of newborn

infants with HIV born in the United States with respect to

whom the attending obstetrician for the birth did not know

the HIV status of the mother.

(B) A determination for each State of any barriers, including legal barriers, that prevent or discourage an obstetrician from making it a routine practice to offer pregnant

women an HIV test and a routine practice to test newborn

infants for HIV disease in circumstances in which the obstetrician does not know the HIV status of the mother of the

infant.

(C) Recommendations for each State for reducing the incidence of cases of the perinatal transmission of HIV, including recommendations on removing the barriers identified under subparagraph (B).

If such Institute declines to conduct the study, the Secretary

shall enter into an agreement with another appropriate public

or nonprofit private entity to conduct the study.

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(2) REPORT.—The Secretary shall ensure that, not later than

18 months after the effective date of this section, the study required in paragraph (1) is completed and a report describing

the findings made in the study is submitted to the appropriate

committees of the Congress, the Secretary, and the chief public

health official of each of the States.

(b) PROGRESS TOWARD RECOMMENDATIONS.—Each State shall

comply with the following (as applicable to the fiscal year involved):

(1) For fiscal year 2004, the State shall submit to the Secretary a report describing the actions taken by the State toward

meeting the recommendations specified for the State under subsection (a)(1)(C).

(2) For fiscal year 2005 and each subsequent fiscal year—

(A) the State shall make reasonable progress toward

meeting such recommendations; or

(B) if the State has not made such progress—

(i) the State shall cooperate with the Director of the

Centers for Disease Control and Prevention in carrying

out activities toward meeting the recommendations;

and

(ii) the State shall submit to the Secretary a report

containing a description of any barriers identified

under subsection (a)(1)(B) that continue to exist in the

State; as applicable, the factors underlying the continued existence of such barriers; and a description of how

the State intends to reduce the incidence of cases of the

perinatal transmission of HIV.

(c) SUBMISSION OF REPORTS TO CONGRESS.—The Secretary shall

submit to the appropriate committees of the Congress each report received by the Secretary under subsection (b)(2)(B)(ii).

Subpart III—Certain Partner Notification

Programs

SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS.

(a) IN GENERAL.—In the case of States whose laws or regulations

are in accordance with subsection (b), the Secretary, subject to subsection (c)(2), may make grants to the States for carrying out programs to provide partner counseling and referral services.

(b) DESCRIPTION OF COMPLIANT STATE PROGRAMS.—For purposes

of subsection (a), the laws or regulations of a State are in accordance with this subsection if under such laws or regulations (including programs carried out pursuant to the discretion of State officials) the following policies are in effect:

(1) The State requires that the public health officer of the

State carry out a program of partner notification to inform

partners of individuals with HIV disease that the partners may

have been exposed to the disease.

(2)(A) In the case of a health entity that provides for the performance on an individual of a test for HIV disease, or that

treats the individual for the disease, the State requires, subject

to subparagraph (B), that the entity confidentially report the

positive test results to the State public health officer in a manner recommended and approved by the Director of the Centers

for Disease Control and Prevention, together with such addiVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00092 Fmt 6659 Sfmt 6603 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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tional information as may be necessary for carrying out such

program.

(B) The State may provide that the requirement of subparagraph (A) does not apply to the testing of an individual for HIV

disease if the individual underwent the testing through a program designed to perform the test and provide the results to the

individual without the individual disclosing his or her identity

to the program. This subparagraph may not be construed as affecting the requirement of subparagraph (A) with respect to a

health entity that treats an individual for HIV disease.

(3) The program under paragraph (1) is carried out in accordance with the following:

(A) Partners are provided with an appropriate opportunity to learn that the partners have been exposed to HIV

disease, subject to subparagraph (B).

(B) The State does not inform partners of the identity of

the infected individuals involved.

(C) Counseling and testing for HIV disease are made

available to the partners and to infected individuals, and

such counseling includes information on modes of transmission for the disease, including information on prenatal

and perinatal transmission and preventing transmission.

(D) Counseling of infected individuals and their partners

includes the provision of information regarding therapeutic

measures for preventing and treating the deterioration of

the immune system and conditions arising from the disease, and the provision of other prevention-related information.

(E) Referrals for appropriate services are provided to

partners and infected individuals, including referrals for

support services and legal aid.

(F) Notifications under subparagraph (A) are provided in

person, unless doing so is an unreasonable burden on the

State.

(G) There is no criminal or civil penalty on, or civil liability for, an infected individual if the individual chooses

not to identify the partners of the individual, or the individual does not otherwise cooperate with such program.

(H) The failure of the State to notify partners is not a

basis for the civil liability of any health entity who under

the program reported to the State the identity of the infected individual involved.

(I) The State provides that the provisions of the program

may not be construed as prohibiting the State from providing a notification under subparagraph (A) without the

consent of the infected individual involved.

(4) The State annually reports to the Director of the Centers

for Disease Control and Prevention the number of individuals

from whom the names of partners have been sought under the

program under paragraph (1), the number of such individuals

who provided the names of partners, and the number of partners so named who were notified under the program.

(5) The State cooperates with such Director in carrying out a

national program of partner notification, including the sharing

of information between the public health officers of the States.

94

(c) REPORTING SYSTEM FOR CASES OF HIV DISEASE.— (1) PREFERENCE IN MAKING GRANTS THROUGH FISCAL YEAR

2003.—In making grants under subsection (a) for each of the fiscal years 2001 through 2003, the Secretary shall give preference

to States whose reporting systems for cases of HIV disease

produce data on such cases that is sufficiently accurate and reliable for use for purposes of section 2618(b)(2)(D)(i).

(2) ELIGIBILITY CONDITION AFTER FISCAL YEAR 2003.—For fiscal year 2004 and subsequent fiscal years, a State may not receive a grant under subsection (a) unless the reporting system

of the State for cases of HIV disease produces data on such

cases that is sufficiently accurate and reliable for purposes of

section 2618(b)(2)(D)(i).

(d) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this section, there are authorized to be appropriated

$30,000,000 for fiscal year 2001, and such sums as may be necessary for each of the fiscal years 2002 through 2005.

* * * * * * *

PART C—EARLY INTERVENTION SERVICES

øSubpart I—Formula Grants for States

øSEC. 2641. ESTABLISHMENT OF PROGRAM.

ø(a) ALLOTMENTS FOR STATES.—For the purposes described in

subsection (b), the Secretary, acting through the Director of the

Centers for Disease Control and Prevention and in consultation

with the Administrator of the Health Resources and Services Administration, shall for each of the fiscal years 1991 through 1995

make an allotment for each State in an amount determined in accordance with section 2649. The Secretary shall make payments, as

grants, to each State from the allotment for the State for the fiscal

year involved if the Secretary approves for the fiscal year an application submitted by the State pursuant to section 2665.

ø(b) PURPOSES OF GRANTS.—

ø(1) IN GENERAL.—The Secretary may not make a grant

under subsection (a) unless the State involved agrees to expend

the grant for the purposes of providing, on an outpatient basis,

each of the early intervention services specified in paragraph

(2) with respect to HIV disease.

ø(2) SPECIFICATION OF EARLY INTERVENTION SERVICES.—The

early intervention services referred to in paragraph (1) are—

ø(A) counseling individuals with respect to HIV disease

in accordance with section 2662;

ø(B) testing individuals with respect to such disease, including tests to confirm the presence of the disease, tests

to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate

therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and

treating conditions arising from the disease;

ø(C) referrals described in paragraph (3);

ø(D) other clinical and diagnostic services with respect to

HIV disease, and periodic medical evaluations of individuals with the disease; and

95

ø(E) providing the therapeutic measures described in

subparagraph (B).

ø(3) REFERRALS.—The services referred to in paragraph

(2)(C) are referrals of individuals with HIV disease to appropriate providers of health and support services, including, as

appropriate—

(A) to entities receiving amounts under part A or B for

the provision of such services;

ø(B) to biomedical research facilities of institutions of

higher education that offer experimental treatment for

such disease, or to community-based organizations or other

entities that provide such treatment; or

ø(C) to grantees under section 2671, in the case of pregnant women.

ø(4) REQUIREMENT OF AVAILABILITY OF ALL EARLY INTERVEN- TION SERVICES THROUGH EACH GRANTEE.—The Secretary may

not make a grant under subsection (a) unless the State involved agrees that each of the early intervention services specified in paragraph (2) will be available through the State. With

respect to compliance with such agreement, a State may expend the grant to provide the early intervention services directly, and may expend the grant to enter into agreements

with public or nonprofit private entities under which the entities provide the services.

ø(5) OPTIONAL SERVICES.—A State receiving a grant under

subsection (a)—

ø(A) may expend not more than 5 percent of the grant

to provide early intervention services through making

grants to hospitals that—

ø(i) for the most recent fiscal year for which the

data is available, have admitted—

ø(I) not fewer than 250 individuals with acquired immune deficiency syndrome; or

ø(II) a number of such individuals constituting

20 percent of the number of inpatients of the hospital admitted during such period;

ø(ii) agree to offer and encourage such services with

respect to inpatients of the hospitals; and

ø(iii) agree that subsections (c) and (d) of section

2644 will apply to the hospitals to the same extent

and in the same manner as such subsections apply to

entities described in such section;

ø(B) may expend the grant to provide outreach services

to individuals who may have HIV disease, or may be at

risk of the disease, and who may be unaware of the availability and potential benefits of early treatment of the disease, and to provide outreach services to health care professionals who may be unaware of such availability and

potential benefits; and

ø(C) may, in the case of individuals who seek early intervention services from the grantee, expend the grant—

ø(i) for case management to provide coordination in

the provision of health care services to the individuals

and to review the extent of utilization of the services

by the individuals; and

96

ø(ii) to provide assistance to the individuals regarding establishing the eligibility of the individuals for financial assistance and services under Federal, State,

or local programs providing for health services, mental

health services, social services, or other appropriate

services.

ø(6) ALLOCATIONS.— ø(A) Subject to subparagraphs (B) and (C), the Secretary

may not make a grant under subsection (a) unless the

State involved agrees—

ø(i) to expend not less than 35 percent of the grant

to provide the early intervention services specified in

subparagraphs (A) through (C) of paragraph (2); and

ø(ii) to expend not less than 35 percent of the grant

to provide the early intervention services specified in

subparagraphs (D) and (E) of such paragraph.

ø(B) With respect to compliance with the agreement

under subparagraph (A), amounts reserved by a State for

fiscal year 1991 for purposes of clauses (i) and (ii) of such

subparagraph may be expended to provide the services

specified in paragraph (5).

ø(C) The Secretary shall ensure that, of the amounts appropriated under section 2650 for fiscal year 1991, an

amount equal to $130,000,000 is expended to provide the

early intervention services specified in subparagraphs (A)

through (C) of paragraph (2).

øSEC. 2642. PROVISION OF SERVICES THROUGH MEDICAID PROVIDERS.

ø(a) IN GENERAL.—Subject to subsection (b), the Secretary may

not make a grant under section 2641 to a State unless, in the case

of any service described in subsection (b) of such section that is

available pursuant to the State plan approved under title XIX of

the Social Security Act for the State—

ø(1) the State will provide the service through a State entity,

and the State entity has entered into a participation agreement under the State plan and is qualified to receive payments

under such plan; or

ø(2) the State will enter into an agreement with a public or

nonprofit private entity under which the entity will provide the

service, and the entity has entered into such a participation

agreement and is qualified to receive such payments.

ø(b) WAIVER REGARDING CERTAIN SECONDARY AGREEMENTS.—

ø(1) IN GENERAL.—In the case of an entity making an agreement pursuant to subsection (a)(2) regarding the provision of

services, the requirement established in such subsection regarding a participation agreement shall be waived by the Secretary if the entity does not, in providing health care services,

impose a charge or accept reimbursement available from any

third-party payor, including reimbursement under any insurance policy or under any Federal or State health benefits program.

ø(2) ACCEPTANCE OF VOLUNTARY DONATIONS.—A determination by the Secretary of whether an entity referred to in paragraph (1) meets the criteria for a waiver under such subparagraph shall be made without regard to whether the entity acVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00096 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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cepts voluntary donations for the purpose of providing services

to the public.

øSEC. 2643. REQUIREMENT OF MATCHING FUNDS.

ø(a) IN GENERAL.—In the case of any State to which the criterion

described in subsection (c) applies, the Secretary may not make a

grant under section 2641 unless the State agrees that, with respect

to the costs to be incurred by the State in carrying out the purpose

referred to in such subsection, the State will, subject to subsection

(b)(2), make available (directly or through donations from public or

private entities) non-Federal contributions toward such costs in an

amount equal to—

ø(1) for the first fiscal year for which such criterion applies

to the State, not less than 162⁄3 percent of such costs ($1 for each $5 of Federal funds provided in the grant);

ø(2) for any second such fiscal year, not less than 20 percent of such costs ($1 for each $4 of Federal funds provided in the

grant);

ø(3) for any third such fiscal year, not less than 25 percent of such costs ($1 for each $3 of Federal funds provided in the

grant); and

ø(4) for any subsequent fiscal year, not less than 331⁄3 per- cent of such costs ($1 for each $2 of Federal funds provided in

the grant).

ø(b) DETERMINATION OF AMOUNT OF NON-FEDERAL CONTRIBU- TION.—

ø(1) IN GENERAL.—Non-Federal contributions required in

subsection (a) may be in cash or in kind, fairly evaluated, including plant, equipment, or services. Amounts provided by the

Federal Government, and any portion of any service subsidized

by the Federal Government, may not be included in determining the amount of such non-Federal contributions.

ø(2) INCLUSION OF CERTAIN AMOUNTS.— ø(A) In making a determination of the amount of nonFederal contributions made by a State for purposes of subsection (a), the Secretary shall, subject to subparagraph

(B), include any non-Federal contributions provided by the

State for HIV-related services, without regard to whether

the contributions are made for programs established pursuant to this title.

ø(B) In making a determination for purposes of subparagraph (A), the Secretary may not include any non-Federal

contributions provided by the State as a condition of receiving Federal funds under any program under this title

(except for the program established in section 2641) or

under other provisions of law.

ø(c) APPLICABILITY OF MATCHING REQUIREMENT.—

ø(1) PERCENTAGE OF NATIONAL NUMBER OF CASES.—

ø(A) The criterion referred to in subsection (a) is, with

respect to a State, that the number of cases of acquired

immune deficiency syndrome reported to and confirmed by

the Director of the Centers for Disease Control and Prevention for the State for the period described in subparagraph (B) constitutes more than 1 percent of the number

of such cases reported to and confirmed by the Director for

the United States for such period.

98

ø(B) The period referred to in subparagraph (A) is the 2-

year period preceding the fiscal year for which the State

involved is applying to receive a grant under section 2641.

ø(2) EXEMPTION.—For purposes of paragraph (1), the number

of cases of acquired immune deficiency syndrome reported and

confirmed for the Commonwealth of Puerto Rico for any fiscal

year shall be deemed to be less than 1 percent.

ø(d) DIMINISHED STATE CONTRIBUTION.—With respect to a State

that does not make available the entire amount of the non-Federal

contribution referred to in subsection (a), the State shall continue

to be eligible to receive Federal funds under a grant under section

2641, except that the Secretary in providing Federal funds under

the grant shall provide such funds (in accordance with the ratios

prescribed in paragraph (1)) only with respect to the amount of

funds contributed by such State.

øSEC. 2644. OFFERING AND ENCOURAGING EARLY INTERVENTION

SERVICES.

ø(a) IN GENERAL.—The Secretary may not make a grant under

section 2641 unless, in the case of entities to which the State provides amounts from the grant for the provision of early intervention services, the State involved agrees that—

ø(1) if the entity is a health care provider that regularly provides treatment for sexually transmitted diseases, the entity

will offer and encourage such services with respect to individuals to whom the entity provides such treatment;

ø(2) if the entity is a health care provider that regularly provides treatment for intravenous substance abuse, the entity

will offer and encourage such services with respect to individuals to whom the entity provides such treatment;

ø(3) if the entity is a family planning clinic, the entity will

offer and encourage such services with respect to individuals to

whom the entity provides family planning services and whom

the entity has reason to believe has HIV disease; and

ø(4) if the entity is a health care provider that provides

treatment for tuberculosis, the entity will offer and encourage

such services with respect to individuals to whom the entity

provides such treatment.

ø(b) SUFFICIENCY OF AMOUNT OF GRANT.—With respect to compliance with the agreement made under subsection (a), an entity to

which subsection (a) applies may be required to offer, encourage,

and provide early intervention services only to the extent that the

amount of the grant is sufficient to pay the costs of offering, encouraging, and providing the services.

ø(c) CRITERIA FOR OFFERING AND ENCOURAGING.—Subject to section 2641(b)(4), an entity to which subsection (a) applies is, for purposes of such subsection, offering and encouraging early intervention services with respect to the individuals involved if the entity—

ø(1) offers such services to the individuals, and encourages

the individuals to receive the services, as a regular practice in

the course of providing the health care involved; and

ø(2) provides the early intervention services only with the

consent of the individuals.

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øSEC. 2645. NOTIFICATION OF CERTAIN INDIVIDUALS RECEIVING

BLOOD TRANSFUSIONS.

ø(a) IN GENERAL.—The Secretary may not make a grant under

section 2641 unless the State involved provides assurances satisfactory to the Secretary that, with respect to individuals in the State

receiving, between January 1, 1978, and April 1, 1985 (inclusive),

a transfusion of whole blood or a blood-clotting factor, the State

will provide public education and information for the purpose of—

ø(1) encouraging the population of such individuals to receive

early intervention services; and

ø(2) informing such population of any health facilities in the

geographic area involved that provide such services.

ø(b) RULE OF CONSTRUCTION.—An agreement made under subsection (a) may not be construed to require that, in carrying out the

activities described in such subsection, a State receiving a grant

under section 2641 provide individual notifications to the individuals described in such subsection.

øSEC. 2646. REPORTING AND PARTNER NOTIFICATION.

ø(a) REPORTING.—The Secretary may not make a grant under

section 2641 unless, with respect to testing for HIV disease, the

State involved provides assurances satisfactory to the Secretary

that the State will require that any entity carrying out such testing

confidentially report to the State public health officer information

sufficient—

ø(1) to perform statistical and epidemiological analyses of the

incidence in the State of cases of such disease;

ø(2) to perform statistical and epidemiological analyses of the

demographic characteristics of the population of individuals in

the State who have the disease; and

ø(3) to assess the adequacy of early intervention services in

the State.

ø(b) PARTNER NOTIFICATION.—The Secretary may not make a

grant under section 2641 unless the State involved provides assurances satisfactory to the Secretary that the State will require that

the public health officer of the State, to the extent appropriate in

the determination of the officer, carry out a program of partner notification regarding cases of HIV disease.

ø(c) RULES OF CONSTRUCTION.—An agreement made under this

section may not be construed—

ø(1) to require or prohibit any State from providing that

identifying information concerning individuals with HIV disease is required to be submitted to the State; or

ø(2) to require any State to establish a requirement that entities other than the public health officer of the State are required to make the notifications referred to in subsection (b).

øSEC. 2647. REQUIREMENT OF STATE LAW PROTECTION AGAINST INTENTIONAL TRANSMISSION.

ø(a) IN GENERAL.—The Secretary may not make a grant under

section 2641 to a State unless the chief executive officer determines

that the criminal laws of the State are adequate to prosecute any

HIV infected individual, subject to the condition described in subsection (b), who—

ø(1) makes a donation of blood, semen, or breast milk, if the

individual knows that he or she is infected with HIV and inVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00099 Fmt 6659 Sfmt 6602 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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tends, through such donation, to expose another HIV in the

event that the donation is utilized;

ø(2) engages in sexual activity if the individual knows that

he or she is infected with HIV and intends, through such sexual activity, to expose another to HIV; and

ø(3) injects himself or herself with a hypodermic needle and

subsequently provides the needle to another person for purposes of hypodermic injection, if the individual knows that he

or she is infected and intends, through the provision of the

needle, to expose another to such etiologic agent in the event

that the needle is utilized.

ø(b) CONSENT TO RISK OF TRANSMISSION.—The State laws described in subsection (a) need not apply to circumstances under

which the conduct described in paragraphs (1) through (3) of subsection (a) if the individual who is subjected to the behavior involved knows that the other individual is infected and provides

prior informed consent to the activity.

ø(c) STATE CERTIFICATION WITH RESPECT TO REQUIRED LAWS.—

With respect to complying with subsection (a) as a condition of receiving a grant under section 2641, the Secretary may not require

a State to enact any statute, or to issue any regulation, if the chief

executive officer of the State certifies to the Secretary that the laws

of the State are adequate. The existence of a criminal law of general application, which can be applied to the conduct described in

paragraphs (1) through (3) of subsection (a), is sufficient for compliance with this section.

ø(d) TIME LIMITATIONS WITH RESPECT TO REQUIRED LAWS.—With

respect to receiving a grant under section 2641, if a State is unable

to certify compliance with subsection (a), the Secretary may make

a grant to a State under such section if—

ø(1) for each of the fiscal years 1991 and 1992, the State provides assurances satisfactory to the Secretary that by not later

than October 1, 1992, the State will have in place or will establish the prohibitions described in subsection (a); and

ø(2) for fiscal year 1993 and subsequent fiscal years, the

State has established such prohibitions.

øSEC. 2648. TESTING AND OTHER EARLY INTERVENTION SERVICES

FOR STATE PRISONERS.

ø(a) IN GENERAL.—In addition to grants under section 2641, the

Secretary may make grants to States for the purpose of assisting

the States in providing early intervention services to individuals

sentenced by the State to a term of imprisonment. The Secretary

may make such a grant only if the State involved requires, subject

to subsection (d), that—

ø(1) the services be provided to such individuals; and

ø(2) each such individual be informed of the requirements of

subsection (c) regarding testing and be informed of the results

of such testing of the individual.

ø(b) REQUIREMENT OF MATCHING FUNDS.—

ø(1) IN GENERAL.—The Secretary may not make a grant

under subsection (a) unless the State involved agrees that,

with respect to the costs to be incurred by the State in carrying

out the purpose described in such subsection, the State will

make available (directly or through donations from public or

101

private entities) non-Federal contributions toward such costs in

an amount equal to—

ø(A) for the first fiscal year of payments under the grant, not less than $1 for each $2 of Federal funds provided in the grant; and

ø(B) for any subsequent fiscal year of such payments, not less than $1 for each $1 of Federal funds provided in

the grant.

ø(2) DETERMINATION OF AMOUNT OF NON-FEDERAL CONTRIBU- TION.—Non-Federal contributions required in paragraph (1)

may be in cash or in kind, fairly evaluated, including plant,

equipment, or services. Amounts provided by the Federal Government, and services (or portions of services) subsidized by

the Federal Government, may not be included in determining

the amount of such non-Federal contributions.

ø(c) TESTING.—The Secretary may not make a grant under subsection (a) unless—

ø(1) the State involved requires that, subject to subsection

(d), any individual sentenced by the State to a term of imprisonment be tested for HIV disease—

ø(A) upon entering the State penal system; and

ø(B) during the 30-day period preceding the date on

which the individual is released from such system;

ø(2) with respect to informing employees of the penal system

of the results of such testing of the individual, the State—

ø(A) upon the request of any such employee, provides

the results to the employee in any case in which the medical officer of the prison determines that there is a reasonable basis for believing that the employee has been exposed by the individual to such disease; and

ø(B) informs the employees of the availability to the employees of such results under the conditions described in

subparagraph (A);

ø(3) with respect to informing the spouse of the individual of

the results of such testing of the individual, the State—

ø(A) upon the request of the spouse, provides such results to the spouse prior to any conjugal visit and provides

such results to the spouse during the period described in

paragraph (1)(B); and

ø(B) informs the spouse of the availability to the spouse

of such results under the conditions described in subparagraph (A);

ø(4) with respect to such testing upon entering the State

penal system of such an individual who has been convicted of

rape or aggravated sexual assault, the State—

ø(A) upon the request of the victim of the rape or assault, provides such results to the victim; and

ø(B) informs the victim of the availability to the victim

of such results; and

ø(5) the State, except as provided in any of paragraphs (2)

through (4), maintains the confidentiality of the results of testing for HIV disease in each prison operated by the State or

with amounts provided by the State, and makes disclosures of

such results only as medically necessary.

ø(d) DETERMINATION OF PRISONS SUBJECT TO REQUIREMENT.—

102

ø(1) IN GENERAL.—The Secretary may not make a grant

under subsection (a) unless the State involved agrees that the

requirement established in such subsection regarding the provision of early intervention services to inmates will apply only

to inmates who are incarcerated in prisons with respect to

which the State public health officer, after consultation with

the chief State correctional officer, has, on the basis of the criteria described in paragraph (2), determined that the provision

of such services is appropriate with respect to the public health

and safety.

ø(2) DESCRIPTION OF CRITERIA.—The criteria to be considered

for purposes of paragraph (1) are—

ø(A) with respect to the geographic areas in which inmates of the prison involved resided before incarceration

in the prison—

ø(i) the severity of the epidemic of HIV disease in

the areas during the period in which the inmates resided in the areas; and

ø(ii) the incidence, in the areas during such period,

of behavior that places individuals at significant risk

of developing HIV disease; and

ø(B) the extent to which medical examinations conducted

by the State for inmates of the prison involved indicate

that the inmates have engaged in such behavior.

ø(e) APPLICABILITY OF PROVISIONS REGARDING INFORMED CON- SENT, COUNSELING, AND OTHER MATTERS.—The Secretary may not

make a grant under subsection (a) unless the State involved agrees

that sections 2641(b)(4), 2662, and 2664(c) will apply to the provision of early intervention services pursuant to the grant in the

same manner and to the same extent as such sections apply to the

provision of such services by grantees under section 2641.

ø(f) REQUIREMENT OF APPLICATION.—The Secretary may not

make a grant under subsection (a) unless an application for the

grant is submitted to the Secretary and the application is in such

form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section.

ø(g) RULE OF CONSTRUCTION.—With respect to testing inmates of

State prisons for HIV disease without the consent of the inmates,

the agreements made under this section may not be construed to

authorize, prohibit, or require any State to conduct such testing,

except as provided in subparagraphs (A) and (B) of subsection

(c)(1).

ø(h) AUTHORIZATION OF APPROPRIATIONS.—To carry out this section, there are authorized to be appropriated such sums as may be

necessary for each of the fiscal years 1988 through 1995.

øSEC. 2649. DETERMINATION OF AMOUNT OF ALLOTMENTS.

ø(a) MINIMUM ALLOTMENT.—Subject to the extent of amounts

made available in appropriations Acts, the amount of an allotment

under section 2641(a) for a State for a fiscal year shall be the

greater of—

ø(1) $100,000 for each of the several States, the District of

Columbia, and the Commonwealth of Puerto Rico, and $50,000

for each of the territories of the United States other than the

Commonwealth of Puerto Rico; and

103

ø(2) an amount determined under subsection (b).

ø(b) DETERMINATION UNDER FORMULA.—The amount referred to

in subsection (a)(2) is the product of—

ø(1) an amount equal to the amount appropriated under section 2650 for the fiscal year involved; and

ø(2) a percentage equal to the quotient of—

ø(A) an amount equal to the number of cases of acquired

immune deficiency syndrome reported to and confirmed by

the Director of the Centers for Disease Control and Prevention for the State involved for the most recent fiscal

year for which such data is available; divided by

ø(B) an amount equal to the number of cases of acquired

immune deficiency syndrome reported to and confirmed by

the Director of the Centers for Disease Control and Prevention for the United States for the most recent fiscal

year for which such data is available.

ø(c) CERTAIN ALLOCATIONS BY SECRETARY.— ø(1) DISCRETIONARY GRANTS TO CERTAIN STATES.—After determining the amount of an allotment under subsection (a) for

a fiscal year, the Secretary shall reduce the amount of the allotment of each State by 10 percent. From the amounts available as a result of such reductions, the Secretary shall, on a

discretionary basis, make grants to States receiving allotments

for the fiscal year involved. Such grants shall be made subject

to each of the agreements and assurances required as a condition of receiving grants under section 2641.

ø(2) GRANTS TO CERTAIN POLITICAL SUBDIVISIONS.— ø(A)(i) In the case of a State containing any political

subdivision described in clause (ii), the Secretary shall,

subject to subparagraph (B), make a reduction in the

amount of the allotment under subsection (a) for the State

for each fiscal year in an amount necessary for carrying

out subparagraphs (B) and (C) with respect to the political

subdivision. Any such reduction shall be in addition to the

reduction required in paragraph (1) for the fiscal year involved.

ø(ii) The political subdivision referred to in clause (i) is

any political subdivision that received a cooperative agreement from the Secretary, acting through the Director of

the Centers for Disease Control and Prevention, for fiscal

year 1990 for programs to provide counseling and testing

with respect to acquired immune deficiency syndrome.

ø(B) In the case of a State described in subparagraph

(A), the Secretary shall, from the amounts made available

as a result of reductions under such subparagraph, make

a grant each fiscal year to each political subdivision described in such subparagraph that exists in the State if the

political subdivision involved agrees that the provisions of

subparts II and III will apply to the political subdivision

to the same extent and in the same manner as such subparts apply to entities receiving grants under section

2651(a).

ø(C) Grants under subparagraph (B) for a fiscal year for

a political subdivision shall be provided in an amount

equal to the amount received by the political subdivision

104

in fiscal year 1990 under the cooperative agreement described in subparagraph (A).

ø(d) DISPOSITION OF CERTAIN FUNDS APPROPRIATED FOR ALLOT- MENTS.—

ø(1) IN GENERAL.—Any amounts available pursuant to paragraph (2) shall, in accordance with paragraph (3), be allotted

by the Secretary each fiscal year to States receiving payments

under section 2641(a) for the fiscal year (other than any State

referred to in paragraph (2)(C)). The Secretary shall make payments, as grants, to each such State from any such allotment

for the State for the fiscal year involved.

ø(2) SPECIFICATION OF AMOUNTS.—The amounts referred to

in paragraph (1) are any amounts that are not paid to States

under section 2641(a) as a result of—

ø(A) the failure of any State to submit an application

under section 2651;

ø(B) the failure, in the determination of the Secretary,

of any State to prepare the application in compliance with

such section or to submit the application within a reasonable period of time; or

ø(C) any State informing the Secretary that the State

does not intend to expend the full amount of the allotment

made to the State.

ø(3) AMOUNT OF ALLOTMENT.—The amount of an allotment

under paragraph (1) for a State for a fiscal year shall be an

amount equal to the product of—

ø(A) an amount equal to the amount available pursuant

to paragraph (2) for the fiscal year involved; and

ø(B) the percentage determined under subsection (b)(2)

for the State.

ø(e) TRANSITION RULES.— ø(1) For the fiscal years 1991 through 1993, the amount of

an allotment under section 2641 shall be the greater of the

amount determined under subsection (a) and an amount equal

to the amount applicable under paragraph (2) for the fiscal

year involved.

ø(2) For purposes of paragraph (1)—

ø(A) the amount applicable for fiscal year 1991 is an

amount equal to the amount received by the State involved

from the Secretary, acting through the Director of the Centers for Disease Control and Prevention, for fiscal year

1990 for the provision of counseling and testing services

with respect to HIV;

ø(B) the amount applicable for fiscal year 1992 is 85 percent of the amount specified in subparagraph (A); and

ø(C) the amount applicable for fiscal year 1993 is 70 percent of the amount specified in subparagraph (A).

øSEC. 2649A. MISCELLANEOUS PROVISIONS.

øThe Secretary may not make a grant under section 2641

unless—

ø(1) the State involved submits to the Secretary a comprehensive plan for the organization and delivery of the early

intervention services to be funded with the grant that includes

a description of the purposes for which the State intends to use

such assistance, including—

105

ø(A) the services and activities to be provided and an explanation of the manner in which the elements of the program to be implemented by the State with the grant will

maximize the quality of early intervention services available to individuals with HIV disease throughout the State;

and

ø(B) a description of the manner in which services funded with the grant will be coordinated with other available

related services for individuals with HIV disease; and

ø(2) the State agrees that—

ø(A) the public health agency administering the grant

will conduct public hearings regarding the proposed use

and distribution of the grant;

ø(B) to the maximum extent practicable, early intervention services delivered pursuant to the grant will be provided without regard to the ability of the individual to pay

for such services and without regard to the current or past

health condition of the individual with HIV disease;

ø(C) early intervention services under the grant will be

provided in settings accessible to low-income individuals

with HIV disease; and

ø(D) outreach to low-income individuals with HIV disease will be provided to inform such individuals of the

services available pursuant to the grant.

øSEC. 2650. AUTHORIZATION OF APPROPRIATIONS.

For the purpose of making grants under section 2641, there are

authorized to be appropriated $230,000,000 for fiscal year 1991,

and such sums as may be necessary for each of the fiscal years

1992 through 1995.

* * * * * * *

Subpart II—Categorical Grants

* * * * * * *

SEC. 2653. PREFERENCES IN MAKING GRANTS.

(a) * * *

* * * * * * *

(d) UNDERSERVED AND RURAL AREAS.—Of the applicants who

qualify for preference under this section, the Secretary shall give

preference to applicants that will expend the grant under section

2651 to provide early intervention under such section in rural areas

or in areas that are underserved with respect to such services.

SEC. 2654. MISCELLANEOUS PROVISIONS.

(a) * * *

* * * * * * *

(c) PLANNING AND DEVELOPMENT GRANTS.—

(1) IN GENERAL.—The Secretary may provide øplanning

grants, in an amount not to exceed $50,000 for each such

grant, to public and nonprofit private entities for the purpose

of enabling such entities to provide HIV early intervention

services.¿ planning grants to public and nonprofit private entities for purposes of—

106

(A) enabling such entities to provide HIV early intervention services; and

(B) assisting the entities in expanding their capacity to

provide HIV-related health services, including early intervention services, in low-income communities and affected

subpopulations that are underserved with respect to such

services (subject to the condition that a grant pursuant to

this subparagraph may not be expended to purchase or improve land, or to purchase, construct, or permanently improve, other than minor remodeling, any building or other

facility).

* * * * * * *

(4) AMOUNT AND DURATION OF GRANTS.—

(A) EARLY INTERVENTION SERVICES.—A grant under

paragraph (1)(A) may be made in an amount not to exceed

$50,000.

(B) CAPACITY DEVELOPMENT.—

(i) AMOUNT.—A grant under paragraph (1)(B) may

be made in an amount not to exceed $150,000.

(ii) DURATION.—The total duration of a grant under

paragraph (1)(B), including any renewal, may not exceed 3 years.

ø(4)¿ (5) LIMITATION.—Not to exceed ø1¿ 5 percent of the

amount appropriated for a fiscal year under section 2655 may

be used to carry out this section.

SEC. 2655. AUTHORIZATION OF APPROPRIATIONS.

For the purpose of making grants under section 2651, there are

authorized to be appropriated such sums as may be necessary øin

each of the fiscal years 1996, 1997, 1998, 1999, and 2000.¿ for each

of the fiscal years 2001 through 2005.

Subpart III—General Provisions

* * * * * * *

SEC. 2662. PROVISION OF CERTAIN COUNSELING SERVICES.

(a) * * *

* * * * * * *

(c) COUNSELING OF INDIVIDUALS WITH POSITIVE TEST RESULTS.—

The Secretary may not make a grant under this part unless the applicant for the grant agrees that, if the results of testing for HIV

disease indicate that the individual has the disease, the applicant

will provide to the individual appropriate counseling regarding

such disease, including—

(1) * * *

* * * * * * *

(3) providing counseling øon¿—

(A) on the availability, through the applicant, of early

intervention services;

(B) on the availability in the geographic area of appropriate health care, mental health care, and social and support services, including providing referrals for such services, as appropriate;

107

ø(C) the benefits¿ (C)(i) that explains the benefits of locating and counseling any individual by whom the infected

individual may have been exposed to HIV and any individual whom the infected individual may have exposed to

HIV; and

(ii) that emphasizes it is the duty of infected individuals

to disclose their infected status to their sexual partners and

their partners in the sharing of hypodermic needles; that

provides advice to infected individuals on the manner in

which such disclosures can be made; and that emphasizes

that it is the continuing duty of the individuals to avoid

any behaviors that will expose others to HIV;

(D) on the availability of the services of public health authorities with respect to locating and counseling any individual described in subparagraph (C).

* * * * * * *

SEC. 2664. ADDITIONAL REQUIRED AGREEMENTS.

(a) * * *

* * * * * * *

(g) ADMINISTRATION OF GRANT.—The Secretary may not make a

grant under this part unless the applicant for the grant agrees

that—

(1) * * *

* * * * * * *

(3) the applicant will not expend more than ø7.5¿ 10 percent

including planning and evaluation of the grant for administrative expenses with respect to the grant; øand¿

(4) the applicant will submit evidence that the proposed program is consistent with the statewide coordinated statement of

need and agree to participate in the ongoing revision of such

statement of needø.¿; and

(5) the applicant will provide for the establishment of a quality management program to assess the extent to which medical

services funded under this title that are provided to patients are

consistent with the most recent Public Health Service guidelines

for the treatment of HIV disease and related opportunistic infections and that improvements in the access to and quality of

medical services are addressed.

* * * * * * *

PART D—GENERAL PROVISIONS

SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH.

(a) * * *

(b) PROVISIONS REGARDING PARTICIPATION IN RESEARCH.— (1) IN GENERAL.—With respect to the projects of research

with which an applicant under subsection (a) is concerned, the

Secretary may make a grant under such subsection to the applicant only if the following conditions are met:

(A) * * *

* * * * * * *

108

ø(C) For the first and second fiscal years for which

grants under subsection (a) are to be made to the applicant, the applicant agrees that, not later than the end of

the second fiscal year of receiving such a grant, a significant number of women, infants, children, and youth who

are patients of the applicant will be participating in the

projects of research.

ø(D) Except as provided in paragraph (3) (and paragraph

(4), as applicable), for the third and subsequent fiscal

years for which such grants are to be made to the applicant, the Secretary has determined that a significant number of such individuals are participating in the projects.¿

(C) The applicant will demonstrate linkages to research

and how access to such research is being offered to patients.

* * * * * * *

ø(3) SIGNIFICANT PARTICIPATION; CONSIDERATION BY SEC- RETARY OF CERTAIN CIRCUMSTANCES.—In administering the requirement of paragraph (1)(D), the Secretary shall take into account circumstances in which a grantee under subsection (a) is

temporarily unable to comply with the requirement for reasons

beyond the control of the grantee, and shall in such circumstances provide to the grantee a reasonable period of opportunity in which to reestablish compliance with the requirement.

ø(4) SIGNIFICANT PARTICIPATION; TEMPORARY WAIVER FOR

ORIGINAL GRANTEES.— ø(A) IN GENERAL.—In the case of an applicant under

subsection (a) who received a grant under such subsection

for fiscal year 1995, the Secretary may, subject to subparagraph (B), provide to the applicant a waiver of the requirement of paragraph (1)(D) if the Secretary determines that

the applicant is making reasonable progress toward meeting the requirement.

ø(B) TERMINATION OF AUTHORITY FOR WAIVERS.—The

Secretary may not provide any waiver under subparagraph

(A) on or after October 1, 1998. Any such waiver provided

prior to such date terminates on such date, or on such earlier date as the Secretary may specify.¿

ø(f) APPLICATION.—¿

(f) ADMINISTRATION.— (1) APPLICATION.—A grant under subsection (a) may be made

only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such

manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry

out this section.

(2) QUALITY MANAGEMENT PROGRAM.—A grantee under this

section shall implement a quality management program.

(g) COORDINATION WITH NATIONAL INSTITUTES OF HEALTH.—The

Secretary shall develop and implement a plan that provides for the

coordination of the activities of the National Institutes of Health

with the activities carried out under this section. In carrying out

the preceding sentence, the Secretary shall ensure that projects of

research conducted or supported by such Institutes are made aware

of applicants and grantees under subsection (a), shall require that

109

the projects, as appropriate, enter into arrangements for purposes

of such subsection, and shall require that each project entering into

such an arrangement inform the applicant or grantee under such

subsection of the needs of the project for the participation of

women, infants, children, and youth. In addition, the Secretary, in

coordination with the Director of such Institutes, shall examine the

distribution and availability of appropriate HIV-related research

projects with respect to grantees under subsection (a) for purposes

of enhancing and expanding HIV-related research, especially within

communities that are underrepresented with respect to such projects.

* * * * * * *

(j) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this section, there are authorized to be appropriated such

sums as may be necessary for each of the fiscal years ø1996

through 2000¿ 2001 through 2005.

* * * * * * *

SEC. 2674. EVALUATIONS AND REPORTS.

(a) * * *

* * * * * * *

(c) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to

be appropriated to carry out this section, such sums as may be necessary for each of the fiscal years ø1991 through 1995¿ 2001

through 2005.

* * * * * * *

SEC. 2675. DATA COLLECTION.

For the purpose of collecting and providing data for program

planning and evaluation activities under this title, there are authorized to be appropriated to the Secretary (acting through the Director

of the Centers for Disease Control and Prevention) such sums as

may be necessary for each of the fiscal years 2001 through 2005.

Such authorization of appropriations is in addition to other authorizations of appropriations that are available for such purpose.

SEC. ø2675¿ 2675A. COORDINATION.

ø(a) REQUIREMENT.—The Secretary shall assure that the Health

Resources and Services Administration and the Centers for Disease

Control and Prevention will coordinate the planning of the funding

of programs authorized under this title to assure that health support services for individuals with HIV disease are integrated with

each other and that the continuity of care of individuals with HIV

disease is enhanced. In coordinating the allocation of funds made

available under this title the Health Resources and Services Administration and the Centers for Disease Control and Prevention

shall utilize planning information submitted to such agencies by

the States and entities eligible for support.¿

(a) REQUIREMENT.—The Secretary shall ensure that the Health

Resources and Services Administration, the Centers for Disease

Control and Prevention, the Substance Abuse and Mental Health

Services Administration, and the Health Care Financing Administration coordinate the planning, funding, and implementation of

Federal HIV programs to enhance the continuity of care and prevention services for individuals with HIV disease or those at risk of

such disease. The Secretary shall consult with other Federal agenVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00109 Fmt 6659 Sfmt 6603 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
110

cies, including the Department of Veterans Affairs, as needed and

utilize planning information submitted to such agencies by the

States and entities eligible for support.

(b) REPORT.—The Secretary shall biennially prepare and submit

to the appropriate committees of the Congress a report concerning

the coordination efforts at the Federal, State, and local levels described in this section, including a description of Federal barriers

to HIV program integration and a strategy for eliminating such

barriers and enhancing the continuity of care and prevention services for individuals with HIV disease or those at risk of such disease.

ø(b)¿ (c) INTEGRATION BY STATE.—As a condition of receipt of

funds under this title, a State shall assure the Secretary that

health support services funded under this title will be integrated

with each other, that programs will be coordinated with other

available programs (including Medicaid) and that the continuity of

care and prevention services of individuals with HIV disease is enhanced.

ø(c)¿ (d) INTEGRATION BY LOCAL OR PRIVATE ENTITIES.—As a condition of receipt of funds under this title, a local government or private nonprofit entity shall assure the Secretary that services funded under this title will be integrated with each other, that programs will be coordinated with other available programs (including

Medicaid) and that the continuity of care and prevention services

of individuals with HIV is enhanced.

(e) RECOMMENDATIONS REGARDING RELEASE OF PRISONERS.—

After consultation with the Attorney General and the Director of the

Bureau of Prisons, with States, with eligible areas under part A,

and with entities that receive amounts from grants under part A or

B, the Secretary, consistent with the coordination required in subsection (a), shall develop a plan for the medical case management

of and the provision of support services to individuals who were

Federal or State prisoners and had HIV disease as of the date on

which the individuals were released from the custody of the penal

system. The Secretary shall submit the plan to the Congress not

later than two years after the date of the enactment of the Ryan

White CARE Act Amendments of 2000.

SEC. 2675B. AUDITS.

For fiscal year 2002 and subsequent fiscal years, the Secretary

may reduce the amounts of grants under this title to a State or political subdivision of a State for a fiscal year if, with respect to such

grants for the second preceding fiscal year, the State or subdivision

fails to prepare audits in accordance with the procedures of section

7502 of title 31, United States Code. The Secretary shall annually

select representative samples of such audits, prepare summaries of

the selected audits, and submit the summaries to the Congress.

SEC. 2675C. ADMINISTRATIVE SIMPLIFICATION REGARDING PARTS A

AND B.

(a) COORDINATED DISBURSEMENT.—After consultation with the

States, with eligible areas under part A, and with entities that receive amounts from grants under part A or B, the Secretary shall

develop a plan for coordinating the disbursement of appropriations

for grants under part A with the disbursement of appropriations for

grants under part B in order to assist grantees and other recipients

111

of amounts from such grants in complying with the requirements of

such parts. The Secretary shall submit the plan to the Congress not

later than 18 months after the date of the enactment of the Ryan

White CARE Act Amendments of 2000. Not later than two years

after the date on which the plan is so submitted, the Secretary shall

complete the implementation of the plan, notwithstanding any provision of this title that is inconsistent with the plan.

(b) BIENNIAL APPLICATIONS.—After consultation with the States,

with eligible areas under part A, and with entities that receive

amounts from grants under part A or B, the Secretary shall make

a determination of whether the administration of parts A and B by

the Secretary, and the efficiency of grantees under such parts in

complying with the requirements of such parts, would be improved

by requiring that applications for grants under such parts be submitted biennially rather than annually. The Secretary shall submit

such determination to the Congress not later than two years after

the date of the enactment of the Ryan White CARE Act Amendments

of 2000.

(c) APPLICATION SIMPLIFICATION.—After consultation with the

States, with eligible areas under part A, and with entities that receive amounts from grants under part A or B, the Secretary shall

develop a plan for simplifying the process for applications under

parts A and B. The Secretary shall submit the plan to the Congress

not later than 18 months after the date of the enactment of the Ryan

White CARE Act Amendments of 2000. Not later than two years

after the date on which the plan is so submitted, the Secretary shall

complete the implementation of the plan, notwithstanding any provision of this title that is inconsistent with the plan.

øSEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

ø(a) IN GENERAL.—Subject to subsection (b), there are authorized

to be appropriated to make grants under parts A and B, such sums

as may be necessary for each of the fiscal years 1996 through 2000.

ø(b) DEVELOPMENT OF METHODOLOGY.—

ø(1) IN GENERAL.—With respect to each of the fiscal years

1997 through 2000, the Secretary shall develop and implement

a methodology for adjusting the percentages allocated to part

A and part B to account for grants to new eligible areas under

part A and other relevant factors. Not later than July 1, 1996,

the Secretary shall prepare and submit to the appropriate committees of Congress a report regarding the findings with respect to the methodology developed under this paragraph.

ø(2) FAILURE TO IMPLEMENT.—If the Secretary determines

that such a methodology under paragraph (1) cannot be developed, there are authorized to be appropriated—

ø(A) such sums as may be necessary to carry out part A

for each of the fiscal years 1997 through 2000; and

ø(B) such sums as may be necessary to carry out part B

for each of the fiscal years 1997 through 2000.¿

SEC. 2677. AUTHORIZATION OF APPROPRIATIONS.

(a) PART A.—For the purpose of carrying out part A, there are authorized to be appropriated such sums as may be necessary for each

of the fiscal years 2001 through 2005.

112

(b) PART B.—For the purpose of carrying out part B, there are authorized to be appropriated such sums as may be necessary for each

of the fiscal years 2001 through 2005.

* * * * * * *

PART F—DEMONSTRATION AND TRAINING

* * * * * * *

Subpart II—AIDS Education and Training Centers

SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS.

(a) SCHOOLS; CENTERS.— (1) IN GENERAL.—The Secretary may make grants and enter

into contracts to assist public and nonprofit private entities

and schools and academic health science centers in meeting the

costs of projects—

(A) øtraining¿ to train health personnel, including practitioners in programs under this title and other community

providers, in the diagnosis, treatment, and prevention of

HIV disease, including the prevention of the perinatal

transmission of the disease øand including¿, including

measures for the prevention and treatment of opportunistic infections, and including (as applicable to the type of

health professional involved), prenatal and other gynecological care for women with HIV disease;

(B) to train the faculty of schools of, and graduate departments or programs of, medicine, nursing, osteopathic

medicine, dentistry, public health, allied health, and mental health practice to teach health professions students to

provide for the health care needs of individuals with HIV

disease; øand¿

(C) to develop and disseminate curricula and resource

materials relating to the care and treatment of individuals

with such disease and the prevention of the disease among

individuals who are at risk of contracting the diseaseø.¿;

and

(D) to develop protocols for the medical care of women

with HIV disease, including prenatal and other gynecological care for such women.

* * * * * * *

(b) DENTAL SCHOOLS.— ø(1) IN GENERAL.—The Secretary may make grants to assist

dental schools and programs described in section 777(b)(4)(B)

with respect to oral health care to patients with HIV disease.¿

(1) IN GENERAL.— (A) GRANTS.—The Secretary may make grants to dental

schools and programs described in subparagraph (B) to assist such schools and programs with respect to oral health

care to patients with HIV disease.

(B) ELIGIBLE APPLICANTS.—For purposes of this subsection, the dental schools and programs referred to in this

subparagraph are dental schools and programs that were

described in section 777(b)(4)(B) as such section was in efVerDate 11-MAY-2000 01:51 Jul 27, 2000 Jkt 079006 PO 00000 Frm 00112 Fmt 6659 Sfmt 6603 E:\HR\OC\HR788.XXX pfrm03 PsN: HR788
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fect on the day before the date of enactment of the Health

Professions Education Partnerships Act of 1998 (Public

Law 105–392) and in addition dental hygiene programs

that are accredited by the Commission on Dental Accreditation.

(2) APPLICATION.—Each dental school or program described

in section ø777(b)(4)(B)¿ the section referred to in paragraph

(1)(B) may annually submit an application documenting the

unreimbursed costs of oral health care provided to patients

with HIV disease by that school or hospital during the prior

year.

* * * * * * *

(5) COMMUNITY-BASED CARE.—The Secretary may make

grants to dental schools and programs described in paragraph

(1)(B) that partner with community-based dentists to provide

oral health care to patients with HIV disease in unserved areas.

Such partnerships shall permit the training of dental students

and residents and the participation of community dentists as

adjunct faculty.

(c) AUTHORIZATION OF APPROPRIATIONS.—

(1) SCHOOLS; CENTERS.—For the purpose of grants under

subsection (a), there are authorized to be appropriated such

sums as may be necessary for each of the øfiscal years 1996

through 2000¿ fiscal years 2001 through 2005.

ø(2) DENTAL SCHOOLS.—For the purpose of grants under subsection (b), there are authorized to be appropriated such sums

as may be necessary for each of the fiscal years 1996 through

2000.¿

(2) DENTAL SCHOOLS.—

(A) IN GENERAL.—For the purpose of grants under paragraphs (1) through (4) of subsection (b), there are authorized to be appropriated such sums as may be necessary for

each of the fiscal years 2001 through 2005.

(B) COMMUNITY-BASED CARE.—For the purpose of grants

under subsection (b)(5), there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2001 through 2005.

* * * * * * *

(114)

ADDITIONAL VIEWS

While I support the overall goal of the Coburn-Waxman Ryan

White CARE Act Amendments of 2000, H.R. 4807, I must take

issue with one key provision of the bill, the ‘‘hold harmless’’ provision for Title I Eligible Metropolitan Areas (EMAs). I herewith express my strong objections to this provision and urge that it be

modified.

The original CARE Act legislation of 1990 included two factors

in Title I formula grants: cumulative AIDS cases and ‘‘density.’’

The ‘‘density factor’’ took into account the number of AIDS cases

per 100,000 people in a given EMA. When the CARE Act was reauthorized in 1996, the criteria for Title I formula grants were

changed. A ‘‘ten year weighted case band,’’ which gives greater

‘‘weight’’ to recently diagnosed AIDS cases on the theory that this

information is more likely to measure ‘‘living AIDS cases,’’ was substituted for the count of cumulative AIDS cases and the density

factor was eliminated entirely. These changes, particularly the removal of the density factor, necessitated the inclusion of a ‘‘hold

harmless’’ provision to prevent EMAs from experiencing dramatic

funding losses.

Under current law, a Title I EMA can lose no more than one percent of its funding each year, allowing for a five percent loss over

five years. H.R. 4807 would alter this dramatically by allowing an

EMA to lose 25 percent of its funding over five years. The result

will be a rapid decline among systems of care and reduced access

to vital HIV/AIDS services.

The Senate bill reauthorizing the CARE Act, S. 2301, alters the

‘‘hold harmless’’ provision to allow for a 10 percent reduction in

funding for an EMA over five years, a doubling of the rate in the

current law. The Senate provision allows for a reasonable redirecting of resources without undermining systems of care through

huge funding losses. I urge the Conferees to adopt the Senate provision when this bill goes to Conference.

The 25 percent formula reduction included in H.R. 4807 is troubling for many reasons. The only EMA likely to experience the full

25% reduction in funding is San Francisco, meaning that this

change will directly impact my constituents.

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It has been stated that San Francisco receives ‘‘too much’’ money

relative to the number of people living with HIV/AIDS. This is

false. The AIDS epidemic is still a national crisis and no EMA, including San Francisco, receives enough CARE Act funding to meet

all the needs of those living with HIV/AIDS. As more people with

HIV live longer due to life-saving but expensive combination therapies, the strain on public health systems is increasing, not decreasing. Reducing an EMA’s Title I funding by 25 percent would seriously destabilize systems of care in that community.

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The ten year weighted case band that is used to allocate Title I

formula funding seriously undercounts the number of people accessing CARE Act services. As noted previously, a recently diagnosed AIDS case is given greater ‘‘weight’’ under this formula.

However, the use of highly active antiretroviral therapy has made

this method of measurement far less accurate. Combination therapies have allowed many people with AIDS to live longer than 10

years and prevented many with HIV from advancing to an AIDS

diagnosis as quickly as in the past. As a result, more people than

ever are utilizing CARE Act services but many of them aren’t being

counted in the current Title I formula methodology. The hold harmless provision in H.R. 4807 would have the effect of punishing

EMAs like San Francisco for effective intervention to care for and

prolong the lives of those with HIV.

Proponents of the 25 percent hold harmless provision have offered a per capita analysis of each EMA to show that San Francisco

receives too much in CARE Act funds. This argument is misleading

and obscures the fact that CARE Act funding is designed to support public health systems in cities where large numbers of AIDS

cases threaten the system with collapse and is not tied to individuals with AIDS. A per capita analysis ignores other relevant factors as well, such as the wide variance in cost of care among geographic areas, making direct comparison very difficult. Similarly,

CARE Act services are accessed at varying rates in different areas.

I support the reauthorization of the Ryan White CARE Act; however, it’s vital that the more moderate Senate position on the hold

harmless issue be adopted in Conference and I urge my colleagues

to do so.

ANNA G. ESHOO.

Æ