T he Ryan White HIV/AIDS Program makes federal funds available to eligible metropolitan areas, states and local community-based organizations to provide a number of health care services for HIV/AIDS patients, including medical care, drug treatments, dental care, home health care, and outpatient mental health and substance abuse treatment. The Centers for Disease Control and Prevention (CDC) estimates that more than 1.2 million people in the United States have HIV/AIDS. The Ryan White HIV/AIDS Program reports that in 2014 it served 512,214 low-income people with HIV/AIDS, 25.4% of whom were uninsured and 64.2% of whom were living at or below 100% of the federal poverty level. The majority of clients in 2014 were male (70.6% male, 28.3% female, 1.1% transgender), from racial/ethnic minority populations (47.2% Black/African American, 22.2% Hispanic/Latino, 0.5% American Indian/Alaska Native, 1.2% Asian, 0.2% Native Hawaiian/Pacific Islander, 1.8% Multiple Races, 27% white), and aged 50 years and older (40.4%). The Ryan White HIV/AIDS Program states that in 2014, 80.4% of clients were retained in HIV medical care (218,758 clients of 272,193 total clients). Clinical research has demonstrated that treatment of HIV patients with anti-HIV (also called antiretroviral) medication reduces the amount of virus in the blood to very low levels (also called viral suppression) and lowers the risk of HIV transmission by 96%. The Ryan White HIV/AIDS Program indicates that in 2014, 81.4% of clients achieved viral suppression (231,140 clients of 283,811 total clients). Among youth aged 13-24 years, retention in care was lower (10,988 youth clients of 14,639 total youth clients, or 75.1%) than the national Ryan White HIV/AIDS Program average and viral suppression was much lower (10,407 youth clients of 16,117 total youth clients, or 64.6%). The Ryan White HIV/AIDS Program was established in law in 1990 ( P.L. 101-381 ) and reauthorized and amended in 1996 ( P.L. 104-146 ), 2000 ( P.L. 106-345 ), 2006 ( P.L. 109-415 ), and 2009 ( P.L. 111-87 ). It was enacted as Title XXVI of the Public Health Service (PHS) Act and codified as Parts A, B, C, D, E, F, and G under 42 U.S.C. §300ff-11 et seq. The program is administered by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau. Most of the program funding is distributed to eligible entities based on formulas that take into account the number of people living with HIV/AIDS. FY2016 funding of $2.3 billion is divided among the individual grant programs (Parts A, B, C, D, and F) as shown in Figure 1 . At the end of this report, Table 1 provides FY1991-FY2017 request dollar amounts; the grant programs are summarized in the Appendix . Figure 1. Ryan White HIV/AIDS Program Funding, FY2016Total = $2.3 billionSource: HRSA FY2016 funding provided in the Consolidated Appropriations Act, 2016 (P.L. 114-113).Notes: ADAP = AIDS Drugs Assistance Program; ADR = AIDS Dental Reimbursement Program; AETC = AIDS Education and Training Centers; and SPNS = Special Projects of National Significance. P.L. 111-87 provided specific authorization levels for Parts A, B, C, D, and F for each fiscal year through FY2013, resulting in a four-year reauthorization for the Ryan White HIV/AIDS Program. The program's authority is currently expired, but Congress continues to appropriate funds for the program. P.L. 111-87 required that the Secretary establish a national HIV/AIDS testing goal of 5 million tests annually through programs administered by HRSA and the CDC. The Secretary is required to submit an annual report to Congress on the progress made in achieving the testing goal, including any barriers to meeting the goal, the amount of funding necessary to meet the goal, and the most cost-effective strategies for identifying individuals who are unaware of their HIV status. The Secretary is also required to review each of the programs and activities conducted by CDC as part of the Domestic HIV/AIDS Prevention Activities. Other provisions of P.L. 111-87 are discussed below in the sections of this report on the various parts of the Ryan White HIV/AIDS Program. The Patient Protection and Affordable Care Act of 2010 (ACA, P.L. 111-148 , as amended) contains general provisions to increase access to health insurance and is expected to increase coverage for people living with HIV/AIDS. These provisions include prohibitions on the cancellation of coverage by an insurer due to a preexisting condition, elimination of lifetime caps on insurance benefits and annual limits on coverage, and eligibility for tax subsidies to help low- and middle-income individuals purchase coverage from health insurance exchanges. In addition, states have the option to broaden Medicaid eligibility to include single adults. ACA phases out the Medicare Part D so-called "doughnut hole"—a gap in prescription drug coverage—for individuals who are Medicare-eligible, including individuals with HIV/AIDS. The long-range impact of the health care law on HRSA's Ryan White HIV/AIDS Program (in which the health and treatment services provided under Ryan White are likely to be replaced to some extent by access to such services through health coverage via ACA) remains to be determined and may be of interest to policymakers given that authorization for the Ryan White HIV/AIDS Program has lapsed. Part A provides grant funds for medical and support services to eligible metropolitan and transitional areas with high numbers of people living with HIV, as well as mid-sized areas that have emerging needs for assistance with their HIV-infected populations. The boundaries of the areas are based on the Metropolitan Statistical Areas of the U.S. Census Bureau and may range in size from a single city or county to multiple counties that cross state boundaries. Part A provides funds to eligible metropolitan areas (EMAs) with a population of at least 50,000 that have had more than 2,000 reported AIDS cases in the prior five years. An EMA would stop being eligible if it failed for three consecutive years to have (1) a cumulative total of more than 2,000 reported cases of AIDS during the most recent five calendar years, and (2) a cumulative total of 3,000 or more living cases of AIDS as of December 31 of the most recent year. Part A currently provides grants to 24 EMAs. The 2006 reauthorization ( P.L. 109-415 ) established a grant program for transitional grant areas (TGAs), defined as metropolitan areas with at least 1,000 but fewer than 2,000 cumulative AIDS cases during the most recent five calendar years. Unless a TGA became an EMA, it would continue to be eligible as a TGA until it failed for three years to have (1) at least 1,000 but fewer than 2,000 cumulative cases of AIDS during the most recent five calendar years, and (2) 1,500 or more living cases of AIDS as of December 31 of the most recent calendar year. P.L. 111-87 permits a metropolitan area with a cumulative total of at least 1,400 but less than 1,500 living cases of AIDS to continue to be eligible as a TGA, provided that not more than 5% of the TGA grant award is unobligated at the end of the most recent fiscal year. If a metropolitan area loses TGA eligibility, the entire amount of the former TGA's formula grant for the preceding fiscal year plus $500,000 is made available for Part B grants. During FY2015, Part A provided grants to 29 TGAs and 24 EMAs for a total of 53 jurisdictions. For each Part A grant, 75% of the funds must be spent on core medical services, defined as outpatient/ambulatory medical care services, AIDS Drug Assistance Program (ADAP) treatments and pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost-sharing assistance, home health care, medical nutrition therapy, hospice, home and community-based health services, mental health and substance abuse outpatient services, and medical case management. The core services spending requirement may be waived if (1) there is no waiting list for receiving treatment (under the Part B ADAP program), and (2) core medical services were available to all individuals with HIV/AIDS who were eligible to receive such services under Part A. The remaining 25% of funds may be used for support services, such as outreach services, medical transportation, language services, respite care for persons caring for individuals with HIV/AIDS, and referrals for health care and support services. Payments under Part A (and all other parts of the Ryan White HIV/AIDS Program) must be coordinated with other federal and nonfederal sources of funds. In particular, HRSA must coordinate with Medicare and Medicaid and private health insurance because the Ryan White HIV/AIDS Program is considered to be the "payer of last resort," meaning the program will pay only for services that cannot be provided using another funding source (see text box). Two-thirds of the Part A appropriation is distributed through formula grants, and the remaining one-third is distributed via competitive supplemental grants awarded on the basis of need. The awarding of supplemental Part A grants is based on weighting factors. Under P.L. 111-87 , success in testing for HIV/AIDS and making individuals aware of their HIV status is counted as one-third in making such determinations.