Purpose

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act is a Federal law designed to ensure access to quality healthcare for people living with HIV/AIDS (PLWAs). This program funds primary healthcare and supportive services that remove barriers to care while helping people enter and stay in care. The CARE Act was first enacted by Congress in 1990 and was reauthorized in both 1996 and in 2000. Both reauthorizations included revisions that help ensure that the CARE Act is current with medical and support service advances. Currently, more than 500,000 people access CARE Act services.

This vital program was created to fill in gaps of coverage that may exist for the under/uninsured, and those on Medicare or Medicaid whose benefits may not be sufficient. The CARE Act is designed to ensure that a person living with HIV/AIDS has access to needed services from point of diagnosis through treatment to hospice services, if need be. Although comprehensive in nature, the Ryan White CARE Act is intended to be the payer of last resort for those needing services. Initially, the program was developed to address the burden that would have been placed on the United States' public health infrastructure and the emergency care sites that were seeing a large number of AIDS patients. Projections from the time it was enacted detail that annual new infections would have strained the health infrastructure to the point of collapse.

In order to bridge gaps in service at the local level, despite being a federal program, the CARE Act utilizes various mechanisms to provide funding to states, cities and individual community based organizations. This multifaceted approach is accompanied by a system of allocating funds based on both formula and competitive grants processes.

The Health Resources Services Administration (HRSA), which oversees the CARE Act for the US Department of Health and Human Services, has adopted the following as the guiding principles for CARE Act programs:

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• Revise care systems to meet emerging needs.

• Ensure access to quality HIV/AIDS care.

• Coordinate CARE Act services with other healthcare delivery systems.

• Evaluate the impact of CARE Act funds and make needed improvements.

Structure

In order to meet the diverse needs of the people living with HIV/AIDS and their individual communities, the CARE Act contains five funding streams; Titles I-IV and Part F. Title I is a combination of formula and competitive funding for metropolitan areas. Title II is a combination of formula and competitive grant funding for state and territory health departments. Title III provides funding to clinics in traditionally underserved rural and urban areas via competitive grants. Title IV provides funding for programs that serve the needs of women, children and their families through competitive grants. Part F provides funding for dental services, a network of AIDS Education and Training Centers, evaluation programs, and Special Projects of National Significance.

Title I: Grants to Eligible Metropolitan Areas

In order to qualify for Title I funding, an Eligible Metropolitan Area (EMA) with a population of more than 500,000 inhabitants must report at least 2,000 AIDS cases during the most recent 5 year period. Currently, there are 51 EMAs. In 1991, the first year of the CARE Act, there were 16 EMAs. Funding for an EMA is sent directly from the Federal Government to the local grantee (typically the Mayor's Office of the largest city in the EMA). Then, the allocation of the funding is determined by a local planning council that is mandated to have PLWA representation. The planning councils then determine how funding for the 24 CARE Act services is to be spent in their EMA.

Title II: Grants to States and Territories

Title II funds are available to the 50 US states, Washington DC, and the territories. Title II is divided into two parts. The first part is funding for the provision of medical care and support services for PLWAs. The second component is the AIDS Drug Assistance Program (ADAP) which funds the purchasing of Anti-Retrovirals and other medications.

Care and Services

Currently, approximately one-third of Title II funding goes toward providing various healthcare and support services. Each state/territory has autonomy over the allocations process for its programs. A majority of care and service dollars are used to support local health departments and community based organizations that provide services to PLWAs.

An additional aspect of the Title II care and service program is the advent, in 2000, of the "emerging community" grants. This new program came about as a result of the fact that metropolitan areas may be dealing with heavy burdens related to the AIDS epidemic, but may not qualify for Title I status. Hence, metropolitan areas that report more than 500 but less than 2,000 AIDS cases in the past 5 years are qualified for this funding.

AIDS Drug Assistance Program (ADAP)

Under Title II, states and territories use federal and local funds to provide medications for PLWA residents of that state/territory. Each grantee has the ability to develop ADAP program rules as they see fit. There are no Federal minimums about what medications should be on an ADAP formulary. Additionally, each grantee is responsible for determining eligibility criteria for PLWA access to the ADAP. States, after reaching a certain threshold of AIDS cases, are required to contribute a certain percentage of funding for ADAP.

As a result of the 2000 reauthorization of the CARE Act, three percent of the overall ADAP appropriation is allocated for grantees indicating "severe need" for added resources.

Title III: Early Intervention Services

Title III competitive award grants are designed to help support and bolster early intervention services for PLWAs in rural and urban core areas. This is done via two methods. The first is the provision of funding to existing providers who wish to increase their HIV treatment capacity. The second is the provision of funding for providers interested in providing HIV services that need additional resources to plan for the capacity building required to deliver the Early Intervention Services.

Early Intervention Services Grants

Title III funding is comprised of competitive grants that are awarded directly to health care providers, rather than to cities or states and territories (as in Title I and II). Typically, Title III funding is provided to university and hospital medical centers, federally-funded Community and Migrant Health Centers, and other clinics.

As the trend for new HIV and AIDS cases has been growing rapidly in the South and other rural areas, many of the Title III Early Intervention Services grants in recent years have been awarded to providers in small towns and rural areas.

Planning Grants and Capacity-Building Grants

The HIV/AIDS epidemic continues to spread into regions and areas that are deficient in HIV/AIDS medical and supportive service providers. In order to combat this, planning grants and capacity-building grants have been established to assist with developing an interested party's ability to provide the needed medical and supportive care.

Title IV: Grants to Serve Women, Children, Youth, and Families

Title IV grants are competitive grants that are designed to meet the special needs that women, children, youth and their families face when living with HIV. These grants help to coordinate medical care for families when one or more family members are living with HIV. Additionally, Title IV helps provide access to services that might otherwise not be available to a family dealing with HIV/AIDS, from neonatal and pediatric specialty care, obstetric and gynecologic care, to clinical trial access. Moreover, Title IV can provide access to medical care for caregivers of HIV positive children as well as supportive services such as emergency housing, transportation, and peer support.

Part F

Part F is comprised of two separate programs that aid in the care and treatment of PLWAs, although not necessarily by providing direct patient services. The two programs are the AIDS Education and Training Centers (AETC) and the Dental Reimbursement program.

AIDS Education and Training Centers

In order to assure that people living with HIV/AIDS receive optimal medical care, the CARE Act funds the AIDS Education and Training Centers (AETC). The AETCs are a system of regional, university-based training programs whose purpose is to educate healthcare providers about advances in the treatment of HIV/AIDS. There are a total of 11 regional centers, and more than 70 associated sites, around the country that are responsible for providing training to physicians, nurses and other health professionals. Additionally, there are four national programs within the AETC network that overarch the regional focus of each AETC. They are:

1. National Minority AETC: intended to improve the quality of care in minority communities by providing training to healthcare professionals that addresses cultural issues around healthcare. Using this approach, the goal is to develop more local leaders and improve minority participation in the healthcare system.

2. National Resource AETC: responsible for developing and providing resources used to educate healthcare professionals.

3. National Evaluation AETC: offers assistance with the development and efficacy measurement of professional health education programs.

4. National Clinicians' Consultation: offers up-to-the-minute information and individualized, expert case consultation.

HIV/AIDS Dental Reimbursement Program

Recognizing that a key to overall healthcare for PLWAs is access to quality dental services, the Ryan White CARE Act makes provision for the reimbursement of dental care services. Aside from being able to maintain sound oral health to prevent or treat oral opportunistic infections, dental care is also strongly linked with a PLWA's ability to maintain nutritional intake, which is vital to combating HIV/AIDS.

Additional Aspects of the CARE Act

Apart from the five structured Titles of the CARE act there are two additional components that reach across all the Titles: The Special Projects of National Significance and the Minority AIDS Initiative.

Special Projects of National Significance

Special Projects of National Significance (SPNS) are novel projects that are undertaken with the purpose of improving the service delivery system for PLWAs. These programs are proposed, implemented, and then evaluated. The findings from these programs are then shared with the entire service community. Additionally, SPNS successes are eventually incorporated and standardized into CARE Act programs. SPNS projects address a wide variety of issues including the development of ways to increase PLWA treatment retention rates, designing programs for PLWAs with multiple health diagnoses (i.e. hepatitis C, diabetes, mental health issues, etc.), and increasing the enrollment in treatment of marginalized populations.

Minority AIDS Initiative

As the HIV/AIDS epidemic has developed in the United States, the number of racial and ethnic minorities severely impacted by HIV/AIDS has increased dramatically. In order to address this issue, in 1999 the Minority AIDS Initiative was funded by Congress to ensure that resources were being utilized to provide medical and supportive services to emerging HIV/AIDS populations. As a result, each Title of the Care Act has a mandate to dedicate a minimum amount of funding to addressing the needs of minorities.