On June 23, the Senate Homeland Security and Governmental Affairs Subcommittee on Federal Financial Management, Government Information, and International Security held a hearing to examine the reauthorization of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (P.L. 101-381).
In his opening remarks, Chair Tom Coburn (R-OK) explained that funding under the Ryan White CARE Act is currently allocated based on the number of AIDS cases in each state, but stated that that number is “only a fraction of the people living with HIV.” He also noted that HIV-positive individuals are more likely to be “women, African American, Hispanic, and living in rural areas.” Sen. Frank Lautenberg (D-NJ) said that the Ryan White CARE Act has contributed to “dramatic breakthroughs in treatment,” but pointed out that HIV/AIDS is “still a serious problem and continues to spread.” He added that in his home state of New Jersey, a third of all new cases are among women.
Deborah Hopson, associate administrator of the Health Resources and Services Administration HIV/AIDS Bureau at the Department of Health and Human Services, said that since the last reauthorization of the Ryan White CARE Act, “we have been able to provide antiretroviral treatment, primary care and support services to over half a million people annually in the United States, Puerto Rico, the Virgin Islands and Pacific basin. Fifty percent of these individuals lived below the Federal Poverty Level, less than 10 percent had any private insurance, and less than 30 percent were enrolled in Medicaid.” She added, “The Ryan White CARE Act programs have provided important benefits to these populations. Overall AIDS mortality is down and lives have been extended with HIV/AIDS medications purchased through the AIDS Drug Assistance Program (ADAP). Pregnant women have been provided with care that has allowed them to give birth to children free from HIV infection, and thousands have received support services that have allowed them to access and remain in health care.” Dr. Hopson called the Ryan White CARE Act “an imperfect instrument in need of revitalization,” adding, “Despite its record levels of funding we continue to face waiting lists for life-saving drugs through the ADAP program and there are marked disparities in access to quality medical treatment across the country. As minority populations are increasingly and disproportionately impacted by HIV/AIDS, changes to existing systems of care designed for an earlier epidemic are increasingly urgent. We are challenged as never before to make sure that Federal funds are directed where they are most needed and used for the most vital purposes.”
Dr. Robert Janssen, director of the Divisions of HIV/AIDS Prevention of the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC), called the “dramatic” decrease in the number of mother-to-child or “perinatal” HIV transmissions “one of the great success stories of HIV prevention.” He explained that “since 2000, CDC estimates that 280-370 HIV-infected infants are born in the United States each year a substantial reduction from the 1,000 to 2,000 perinatal HIV cases estimated to have occurred each year in this country in the early 1990s,” adding, “These declines are due to multiple interventions, such as routine voluntary HIV testing of pregnant women, including the use of rapid HIV tests at delivery for women of unknown HIV status, and the use of antiretroviral therapy by HIV-infected women during pregnancy and infants after birth…We continue to work to further decrease perinatal transmission by promoting active case management for high-risk women, routine opt-out testing, and the use of rapid tests at labor and delivery for mothers whose status is unknown.”
Explaining that “cultural, socioeconomic, and health-related factors” are driving the HIV/AIDS epidemic into minority communities, Dr. Janssen stated, “The rate of HIV diagnosis among African American females in 2003 (53 cases per 100,000 population) was more than 18 times higher than among white females (2.9) and almost five times higher than among Hispanic females (10.9). Among American Indians/Alaska Natives, the rate of HIV diagnosis among males (15.6) was slightly higher than the rate among white males; the rate among females (6.4) was twice the rate of white females.”
In examining Ryan White CARE Act funding, Dr. Janssen explained that “since the beginning of the epidemic, AIDS surveillance has been a cornerstone of national, state, and local efforts to monitor the scope and the impact of the HIV epidemic,” but added, “AIDS surveillance data, however, no longer accurately describes the full extent of the epidemic, as effective therapies slow the progression of HIV disease.” He noted that the CDC “reports HIV infection only from areas conducting confidential name-based reporting because this reporting has been shown to routinely achieve high levels of accuracy and reliability,” adding that “since 1999, CDC has advised states to conduct HIV reporting using the same name-based approach currently used for AIDS surveillance nationwide.”
Testifying on behalf of the Government Accountability Office, Health Care Director Marcia Crosse said if HIV cases had been included in the total number of cases for Ryan White CARE Act funding for FY2004, “about half of the states would have received increased funding and the other half would have received decreased funding. Using two different approaches, we found that at least 11 of the states with increased funding were located in the South, the region with the highest estimated number of people living with HIV or AIDS in 2003.” She added, “All states have established HIV case reporting systems, and the 2000 reauthorization of the CARE Act required that HIV cases be used in determining formula funding no later than FY2007. However, wide differences between states’ HIV case reporting systems in their maturity and reporting methods for instance could affect the use of HIV and AIDS case counts to distribute CARE Act funding because an immature reporting system might not capture an accurate count of a state’s HIV cases.”
Michael Montgomery, director of the California Office of AIDS, highlighted his state’s efforts to prevent perinatal HIV transmission where only 14 cases were reported in 2003: “California has an opt out/opt in process for testing previously untested pregnant women. We treat each case of perinatal transmission as a sentinel event and follow up to determine where the woman fell through the cracks in the health care system. We still find that access to prenatal care is the largest barrier to reducing the number of perinatally acquired infections to zero with many of the women knowing their HIV status before delivery. The lack of access to care and fear of seeking care for non-citizens and substance-abusing women remains the primary barrier.” Mr. Montgomery added, “The prevention of mother-to-child transmission is one of our greatest prevention successes. One way to continue the reduction in cases is to provide hospitals serving the un- and underinsured with HIV rapid tests for use in the labor and delivery setting. This would require resources for the test kits as well as training for hospital staff on counseling and administration of the screening test.”
