The Ryan White HIV/AIDS Treatment Modernization Act (RWTMA) programs, first authorized in 1990 and reauthorized in 1996, 2000 and 2006, work with cities, states and local community-based organizations to provide services to approximately 1 million individuals living with HIV/AIDS and to prevent new infections within the United States. The new law changed how Ryan White funds can be used, with an emphasis on providing life-saving and life-extending services for people living with HIV/AIDS across the country. A majority of RWTMA funds support primary medical care and essential support services. A smaller, but equally critical portion is used to fund technical assistance, clinical training and research on innovative models of care. Headed by Kathi Braswell Principal Investigator at the CORE Center, the funds of the RWTMA are divided into 5 major divisions: Titles I, II, III, IV (now referred to as Parts A, B, C, D).
Part A of the CARE Act provides emergency assistance to Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) that are most severely affected by the HIV/AIDS epidemic. To be an eligible EMA, an area must have reported at least 2,000 AIDS cases in the most recent five years and have a population of at least 50,000. In order to be an eligible TGA, an area must have reported at least 1,000 – 1,999 new AIDS cases in the most recent five years.
Part A funds may be used to provide a continuum of care for persons living with HIV disease with a requirement to provide 75 percent of the award for core medical services and 25 percent for support services. Core services are limited to: outpatient and ambulatory services; AIDS pharmaceutical assistance; oral health; early intervention services; health insurance premium and cost sharing assistance for low-income individuals; home health care; medical nutrition therapy; hospice services; home and community-based health services; mental health services; substance abuse outpatient care; and medical case management including treatment adherence services.
Support services must be linked to medical outcomes and may include: outreach, medical transportation, linguistic services, respite care for person caring for individuals with HIV/AIDS, referrals for health care and other support services, case management, and substance abuse residential services.
Hektoen has been awarded grants for Title I since 1991, when it gained a Title I grant for the provision of HIV services at Cook County’s Fantus Clinic (the precursor to the CORE Center). In the 13 years since, it has been awarded Title I grants for the HIV clinic at Provident Hospital (beginning in 1994); the CCWSHS (beginning in 1999) and the SSHARC (since 2001).
Part B of the CARE Act, provides grants to all 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and five U.S. Pacific Territories or Associated Jurisdictions. Part B grants include a base grant, the AIDS Drug Assistance Program (ADAP) award, ADAP Supplemental grants and grants to States for Emerging Communities-those reporting between 500 and 999 cumulative reported AIDS cases over the most recent 5 years. All funding is distributed via formula and other criteria.
Part B funds may be used to fund 75% core medical services which include: outpatient and ambulatory health services, ADAP, AIDS pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost sharing assistance, home health care, medical nutrition therapy, hospice care, community-based health services, substance abuse outpatient care, medical case management, include treatment adherence services.
The remaining 25% must fund support services that are needed for individuals with HIV/AIDS to achieve their medical outcomes (such as respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services.
Hektoen has been awarded grants for Title II since 1990. Since then, it has been awarded Title II grants for HIV care services at the CORE Center (since 1990), Provident Hospital (since 1995), Cook County Austin Health Center (since 1999), and the SSHARC (since 2001).
Part C of the CARE Act provides grants directly to service providers such as ambulatory medical clinics to support outpatient HIV early intervention services and ambulatory care. Part C also funds planning grants, which support organizations in more effectively delivering HIV/AIDS care and services and capacity development grants to enhance a grantees capacity to develop, strengthen, or expand access to high quality HIV primary health care services for people living with HIV or who are at risk of infection in underserved or rural communities and communities of color.
Part C has three components: 1) capacity building; 2) planning; and 3) early intervention services.
1)The Capacity Building Development Grant Program funds are designed to assist public and nonprofit entities in their efforts to strengthen their organizational infrastructure and to enhance their capacity to develop, enhance, or expand access to high quality HIV primary health care services for people living with HIV or who are at risk of infection in underserved or rural communities and communities of color. Activities supported by this grant funding are not intended for long-term activities. Instead, the activities should be of a short-term nature and should be completed by the end of the one year project period.
For the purposes of this grant program, capacity development is defined as activities that promote organizational infrastructure development and that will lead to the delivery of improvement of HIV primary care services.
Eligible applicants must be public or private nonprofit entities that are or intend to become comprehensive HIV primary care providers. Current Ryan White Programs service providers are eligible to apply for funding. Faith-based and community-based organizations are eligible to apply for these funds.
2)The Planning Grant Program funds eligible entities in their efforts to plan for the provision of high-quality comprehensive HIV primary health care services in rural or urban underserved areas and communities of color. Planning grant funds are intended for a period of one year. Planning grants support the planning process and do not fund any service delivery or patient care.
Eligible applicants must be public or private nonprofit entities that are or intend to become comprehensive HIV primary care providers. Current Ryan White Programs Part C EIS and Part D Program grant recipients are eligible only if they are proposing to open a new program. Faith-based and community-based organizations are eligible to apply for these funds.
3)Early Intervention Services Grants funds comprehensive primary health care in an outpatient setting for people living with HIV disease. The Part C Program divides allowable costs among five Part C Cost Categories. These categories are Early Intervention Services Costs, Core Medical Services costs, Support Services Costs, Quality Management Costs, and Administrative costs.
Early Intervention Services Costs are those costs associated with the direct provision of medical care and make up at least 50 percent of a grantee budget. Services include:
• Primary care providers
• Lab, x-ray, and other diagnostic tests
• Medical/dental equipment and supplies
• Medical Case Management
• Electronic Medical Records
• Patient Education, in conjunction with medical care
• Transportation for clinical care provider staff to provide care
• Other clinical and diagnostic services regarding HIV/AIDS and periodic medical evaluations of individuals with HIV/AIDS
Core Medical Services Costs include those listed above plus the following:
• HIV Counseling
• The following core medical services have historically been paid by Parts A or B (Titles I or II) but not Part C (Title III), and should only be provided by Part C with justification.
• AIDS Drug Assistance Program
• Health Insurance Premium and cost sharing assistance for low income individuals
• Home health care
• Hospice Services
• Home and community-based health services as defined under Part B
Clinical Quality Managements Costs are those costs required to maintain a clinical quality management program. With a HAB expectation that no more than 5 percent of the grant be spent on Clinical Quality Management, examples include:
• Continuous Quality Improvement (CQI) activities
• Clinical Quality management coordination
• Data collection for clinical quality management purposes
• Consumer involvement to improve services
• Staff training/technical assistance (including travel and registration) to improve services- this includes the annual clinical update and the biennial All Grantee Meeting, as well as local travel to meetings not directly related to patient care
Support Services Costs are those costs for services that are needed for individuals with HIV/AIDS to achieve their medical outcomes. Support Services Costs include:
• Patient transportation to medical appointments
• Staff travel to provide support services
• Outreach to identify people with HIV, or at-risk of contracting HIV, to educate them about the benefits of early intervention and link them into primary care
• Translation services, including interpretation services for deaf persons
• Patient education materials for general use
• Participation in Statewide coordinated Statement of Need process
• Patient advocates to maintain access to care
• Respite Care (historically paid by Parts A or B (Titles I or II) but not Part C (Title III), and should only be provided by Part C with justification)
Administrative Costs are those not directly associated with service provision. By law, no more than 10 percent of a Federal Part C EIS budget can be allocated to administrative costs. Examples of administrative costs include:
• Indirect Costs, which are allowed only if the applicant has a negotiated indirect cost rate approved by a recognized federal agency. Indirect Costs are those costs incurred by the organization that are not readily identifiable with a particular project or program, but are considered necessary to the operation of the organization and performance of its programs. All indirect costs are considered administrative for the Part C EIS program and therefore are subject to the 10 percent limitation on administrative expense.
• Rent, utilities, and other facility support costs
• Personnel costs and fringe benefits of staff members responsible for the management of the project (such as Project Director and program coordinator), non-CQI program evaluation, non-CQI data collection/reporting, supervision, and other administrative, fiscal, or clerical duties
• Telecommunications, including telephone, fax, paper and internet access
• Liability insurance
• Office supplies
• Payroll/Accounting services
• Computer hardware/software not directly related to patient care
• Program evaluation, including data collection for evaluation
Part D of the CARE Act : Early Intervention Services Grant provides family centered care involving outpatient or ambulatory care (directly or through contracts) for women, infants, children, and youth with HIV/AIDS.
Grantees are expected to provide care, treatment, and support services or create a network of medical and social service providers, who collaborate to supply services.
Part D funds the following services:
• Family-centered primary and specialty medical care
• Support services
• Logistical support and coordination
In addition grantees are to educate clients about research and research opportunities and inform all clients about the benefits of participation, and how to enroll in research.
The Title IV programs (now referred to as Part D) started in 1988 as the Pediatric AIDS Demonstration Projects. The projects originally served infected infants and children, infected pregnant women and their families. They provided supportive care to families to help infected children receive medical care. Beginning in 1994, Congress funded these projects under Title IV of the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act. In 1999, in response to the alarming growth of HIV infected youth being identified, the HIV/AIDS bureau (HAB) funded a Youth Initiative, which currently supports 17 youth specific programs across the nation. In 2006, Congress funded the Part D programs under Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006.
The Part D program has improved access to a comprehensive system of health and social services for populations least able to cope with HIV/AIDS.