House Ryan White CARE Act Reauthorization Bill's Mandatory HIV Testing Provisions Will Negatively Impact Women of Color
The National Minority AIDS Council supports the swift passage of the reauthorization of the Ryan White CARE Act. However, NMAC vehemently opposes any provisions in the bill which call for mandatory HIV testing of pregnant women or newborns as a condition for receipt of CARE Act funds. In spite of strong opposition to mandatory HIV testing provisions by AIDS advocates and pediatric providers, and the call for routine counseling and voluntary HIV testing as a viable and more effective alternative, Representatives Coburn of Oklahoma and Waxman of California continued to press for inclusion of a mandatory HIV testing provision in H.R. 1872. Because the bill was placed on a suspension calendar for consideration by the full House of Representatives, the Coburn-Waxman amendment was included as a managers amendment to the bill and therefore did not have to undergo normal introduction, debate and voting process. As a result, on September 18, 1995 by a unanimous voice vote, the House
of Representatives authorized the Ryan White CARE Reauthorization Act of 1995 (H.R. 1872), which included the Coburn-Waxman amendment.
This amendment requires states to demonstrate knowledge of the HIV status of 95% of the newborn infants born in the state within two years of implementation of the reauthorized CARE Act. If they are unable to do so, then they must implement mandatory HIV testing programs for pregnant women and newborns in order to receive Title II CARE Act funds.
NMAC supports the Kassebaum/Kennedy provision in the Senate Ryan White CARE Reauthorization Act of 1995, ( S. 641), that establishes a $10 million discretionary grant program for 11 states where 80% of the cases of perinatal HIV transmission occur, for counseling, outreach services, voluntary HIV testing and the costs associated with implementation of the CDC guidelines for counseling and voluntary HIV testing of pregnant women. This amendment passed by a voice vote of 97-3 on the Senate floor
on July 27, 1995 and surprisingly had the support of Senator Jesse Helms.
The differences in the Senate and House versions of the reauthorization bill will have to be worked out in conference, following the October 2-10th Congressional recess. Conferees are expected to be Senators Kassebaum (R-Kansas), Jeffords (R-Vermont), Frist (R-Tennessee), Kennedy (D-Massachusetts), Dodd (D-Connecticut), and Representatives Bliley (R- Virginia), Bilirakis (R- Florida), Coburn (R-Oklahoma),Dingell (D-Michigan) and Waxman (D-California). The voices of people of color need to be heard on this issue by the conferees.
NMAC believes that neither mandatory testing of pregnant/post-partum women nor newborns will serve to effectively reduce the rate of perinatal HIV transmission. Mandatory HIV provisions will have an adverse impact on women, particularly women of color who are already disproportionately affected by HIV/AIDS and experience significant barriers to access to HIV care. Rates of HIV infection
and AIDS among all women are increasing. However, despite regional variations, women of color bear the burden of HIV infection among women. African American and Latina women carry the greatest burden: while together they account for 21% of the total population of women in the United States, they represent 75% of the cumulative AIDS cases reported among women. This provision may function to drive women away from treatment because of their fears of the negative consequences of an HIV positive test. Many women of color and women with substance abuse histories, (who already experience high rates of late or no prenatal care), may circumvent the health care delivery system if mandatory testing is implemented because of fear of loss of employment, health insurance or custody of their children.
While we believe the intent of such an amendment, -- reduction of the perinatal transmission of HIV infection and access to early interventions for both mother and infant -- are commendable public
health goals, we are seriously concerned that such an amendment will ultimately function to undermine the very purpose of the Ryan White CARE Act: to facilitate access to a continuum of HIV treatment and care. Furthermore, testing newborns for HIV infection will not serve to prevent perinatal transmission. By the time a child is born, taking measures to prevent HIV transmission from mother to child, such as AZT therapy, will not work. It is simply too little, too late. AZT is only effective if taken perinatally and will not prevent the transmission of HIV infection if administered only after birth.
Finally, mandatory testing of newborns does not realize any public health goal which cannot be achieved through less intrusive and more effective measures. Prevention of perinatal transmission and provision of early interventions will be more effectively and efficiently achieved through the provision of comprehensive prenatal care to all pregnant women. Such care should include: counseling about the risks of HIV
infection and the availability of voluntary HIV testing; the provision of information about the options available to prevent perinatal transmission, and access to treatment and care for the woman as well as her newborn.
To require the implementation of mandatory HIV testing for pregnant women and newborns as a condition for states to receive Title II CARE Act funds is unconscionable and ironic, given the relentless drive in Congress to dismantle the Medicaid entitlement program. Medicaid provides health care coverage to over 36 million low income Americans, including 40% of all people with HIV infection in the United States and over 90% of the children with HIV/AIDS. Medicaid is the largest single payor of medical services for people living with HIV/AIDS. Public spending on HIV/AIDS health care services totalled $3.75 billion in 1994. Medicaid funds covered 69.7% of these expenditures, while Ryan White CARE Act funds covered 15.4%. The current proposals in the House and Senate to reform
Medicaid would undermine the program and jeopardize the health care coverage of millions of persons living with HIV/AIDS. Women of color and children would be highly impacted by these "reforms" precisely because they experience a high incidence of poverty and lack of health insurance. One in eight women nationally lives in poverty. However women of color are disproportionately represented among the ranks of the poor: 28.3% of African American women, 24.2% of Hispanic women, 12.8% of Asian women and 28.9% of Native American women live in poverty as compared with 9.8% of all White women. If these Medicaid proposals are passed, then the very access to comprehensive prenatal, primary and HIV care that women need, will be unavailable to tens of thousands of poor women. These proposals are misguided and will only serve to further penalize women, and most severely women of color.