“Medical breakthroughs have dramatically transformed HIV infection for many into a chronic manageable disease … While the face of AIDS has changed, our federal government has been slow to adapt to those changes,” said Senator Tom Coburn in opening a June 23 oversight hearing on the Ryan White CARE Act.

Last year the program funneled more than $2 billion to HIV/AIDS care and treatment within the United States. Medicare and Medicaid provided even more medical care for people living with HIV.

The Oklahoma conservative and pediatrician choked up in recalling the baby girl he delivered 20 years ago who later died of AIDS at the age of seven. As a member of the House he played a leading role in reauthorization of the CARE Act in 2000 and he subsequently served as co-chair of the Presidential Advisory Committee on HIV/AIDS.

“The CARE Act continues to distribute federal funds based not upon the number of people with HIV but rather AIDS, only a fraction of the total population of those living with HIV,” Coburn said. “Studies have shown that those with HIV but not AIDS are much more likely to be women, African-American, Hispanic, and those who live in rural areas.”

He said he wants resources directed to where the disease is headed rather than to where it was a decade ago. Previous funding formulas were based upon cumulative AIDS caseloads, including those who have been dead for more than a decade, rather than the current HIV caseload. But that will change beginning with the fiscal year 2007 budget.

He criticized the “hold harmless” provision of the last reauthorization, which limits reductions in funding. Last year San Francisco received 92 percent of all such funding; some $7.3 million. As a result, San Francisco receives twice the amount per AIDS case as every other metropolitan area, he said.

“The city finds itself in the unique position where it must find ways to spend excess money on non-essential services while its reported AIDS cases continue to drop,” Coburn charged. “In sharp contrast, the largest AIDS service provider in the country, in Washington, D.C., is faced with dire financial problems that have forced the closing of several offices, massive staff layoffs despite a growing population affected by HIV/AIDS.

“This incredible cost [of drugs] to provide essential treatment underscores the need to prioritize core medical services and effective prevention,” Coburn said.

The Government Accountability Office (GAO) released a 45-page analysis of factors impacting Titles I and II of Ryan White at the hearing. Title I supports eligible metropolitan areas (EMAs), the cities first and hardest hit by the epidemic, while Title II covers the AIDS Drug Assistance Program (ADAP).

States with EMAs receive more funding per AIDS case than jurisdictions without EMAs because cases within EMAs are counted twice, the report said. It compared Connecticut (5,363 cases) and two EMAs with South Carolina (5,563 cases) and no EMAs, and found that Connecticut received $6 million more in funding in fiscal year 2004. That was 29 percent, or $1,275 more per AIDS case.

The Title I hold harmless provision went almost entirely to San Francisco (91.6 percent). The second ranking beneficiary was Kansas City, which received only 1.7 percent of that funding.

“San Francisco received $1,020 more in base grant funding per AIDS case than did EMAs that did not receive hold harmless funding,” the report stated. “[Because of this] San Francisco, which had 7,216 AIDS cases in fiscal year 2004, received a base grant equivalent to what an EMA with approximately 13,245 AIDS cases (84 percent more) would have received base on the proportion of cases.”

It found that the shift from a formula based on AIDS cases to one based on HIV cases, which will occur with fiscal years 2007, would shift funds to locations that have a more established or mature names-based reporting system. That is most often in the South, where the epidemic appears to be spreading most rapidly.

The South includes Florida and Texas, states with the third and fourth largest caseloads respectively, as well as the District of Columbia, which has the highest prevalence of HIV of any jurisdiction in the nation.

The GAO estimated that approximately half the states will lose and half will gain with the shift in formulas. The changes could be as great as 14 percent or as little as 4 percent, depending on whether and how hold harmless provisions are included in a reauthorized bill.

In the most extreme scenario for ADAP funding, the big losers would be California ($11.8 million), Georgia ($3.5 million), Illinois ($3.2 million), Maryland ($3 million) and Puerto Rico ($3 million). Those states gaining the most would be North Carolina ($4.9 million), Virginia ($3.0 million), Florida ($2.9 million), New Jersey ($2.5 million) and Alabama ($2.5 million).

Robert Janssen, director of HIV prevention at the Centers for Disease Control and Prevention, said, “Having all states collect HIV information in the same manner will ensure that the nation has reliable and valid data to monitor and describe the scope of the epidemic; to assure equitable distribution of resources to those who have greatest need; and to plan for and evaluate prevention, care and treatment programs.”

Most states now report HIV cases by name, some for nearly 20 years, but a number of states are still trying to implement reporting systems using unique identifiers. Among the latter are California, Illinois, Maine, Massachusetts, Rhode Island, Vermont and the District of Columbia.

For the full GAO report “Ryan White CARE Act: Factors that Impact HIV and AIDS Funding and Client Coverage,”

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