The Importance of Ryan White HIV/AIDS Program Support Services in Achieving Undetectable = Untransmittable

Mirabel Levine

The Ryan White HIV/AIDS Program (RWHAP) legislation created one of the only disease-specific programs in the country, reflecting the unique needs of people living with HIV (PLWH). The RWHAP includes 13 core medical services and seventeen support services that provide a safety net for eligible PLWH to access HIV diagnosis, care, and support. RWHAP services optimize HIV-related health outcomes by providing wrap-around support services to low-income PLWH that are not typically available through Medicaid, Medicare, and/or private insurance alone. Support services can improve viral load suppression rates which in turn decreases transmission rates, as described through the U=U framework, an evidenced-based campaign asserting that PLWH who are on antiretroviral therapy (ART) and virologically suppressed do not sexually transmit HIV. RWHAP support services strengthen the effectiveness of RWHAP Part B programs and AIDS Drug Assistance Programs (ADAPs) in bolstering their jurisdictions’ efforts to achieve an end to the HIV epidemic.

The combination of core medical and support services can address RWHAP Part B and ADAP clients’ social determinants of health, which are social and economic factors that lead to health inequalities. The Center for Disease Control (CDC) identifies poverty, education, income, and employment as HIV-specific social determinants of health. By design, support services increase a client’s ability to adhere to care and in turn, achieve viral load suppression by removing non-medical difficulties and risks that the client may be facing that could result in adverse health effects.

Between 2016 and 2017, according to the 2019 National RWHAP Part B and ADAP Monitoring Project Annual Report, the support services that were expanded (i.e., the numbers of clients served or expenditures increased) by the most jurisdictions include: Housing Services (n=25), Food Bank/Home-Delivered Meals (n=23), Non-Medical Case Management (n=21), Emergency Financial Assistance (n=16), and Psychosocial Support Services (n=16). In 2018, the total RWHAP expenditures for support services were almost $69 million, compared to the $62 million spent on support services in 2017. In 2018, this accounted for 13% of the total RWHAP Part B budget.

The states with the highest expenditures for support services per client served were Montana ($1,966), Alaska ($1,912), Missouri ($1,328), and Arizona ($1,168). Of note, Arizona (98%), Montana (90%), and Missouri (88%) reported a significantly higher rate of viral suppression (i.e., percentage of clients whose most recent viral load was less than or equal to 200 copies/mL) than the average RWHAP Part B viral suppression rate (69%) among all jurisdictions. This shows that support services may directly improve health outcomes.

Support services improve the impact of the RWHAP Part B program, including ADAP. RWHAP Part B and ADAP clients could benefit from increases in the number of support services available, as well as increased spending on existing support services. By maximizing allowable spending on support services, RWHAP Part B programs could increase their own effectiveness and clients’ wellbeing. RWHAP Part B programs and ADAPs are critical to the Undetectable = Untransmittable (U=U) campaign as providers of access to a combination of safe and effective treatment, comprehensive medical care, and essential support services.