Passed by Congress and signed into law by President George H.W. Bush in 1990, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was enacted to create and sustain a comprehensive care system that spans the continuum of HIV care. This includes: HIV diagnosis; linkage to, and engagement in, HIV medical care and supportive services; access to state-of-the-art treatment; and durable or sustained viral suppression. Administered by the Health Resources & Services Administration (HRSA) HIV/AIDS Bureau (HAB), the RWHAP was last reauthorized in 2009 and the most recent authorization sunset ended September 30, 2013. The program continues to effectively operate as Congress maintains annual appropriations to it. RWHAP clients have strong outcomes across the HIV care continuum. In 2020, 89.4% of clients receiving RWHAP medical services were virally suppressed.
The RWHAP Part B program ensures state and territorial health departments are funded to provide core medical and support services to eligible clients equitably across urban and rural regions. All 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the six U.S. Pacific Territories/Associated Jurisdictions are eligible to receive Part B program funding. Each jurisdiction’s RWHAP Part B program must customize their administration and service delivery to ensure that they are meeting the needs of the clients they serve within the political and structural environment in which they exist. All RWHAP Part B programs aim to guarantee access to treatments and services that bolster clients’ engagement and retention in care so as to ultimately optimize their viral suppression and overall quality of life. RWHAP Part B programs are comprised of the following key components: core medical/support service delivery; clinical quality management (i.e., a series of activities that focus on enhancing the quality of HIV care provided and increasing access to services); and program administration (i.e., administrative, planning and evaluation, salaries, overhead, client eligibility and enrollment, and data system management and reporting).
The breadth of core medical and support service categories allowable under RWHAP, including Part B, represent a wholistic and comprehensive approach to serving individuals with a chronic disease who experience complex social and structural barriers and/or comorbid conditions. Core medical services – including Early Intervention Services (EIS), Mental Health Services and Substance Use Treatment (Outpatient and Residential) – support eligible clients across the HIV-care continuum by bolstering testing, linkage to, and retention in care for HIV and comorbidities. Meanwhile, RWHAP support services (e.g., Housing Services, Medical Transportation Services) respond to individual’s basic needs, making adherence to and the effectiveness of clinical care possible. The array of RWHAP services ensures that public health priorities (e.g., minimizing new infections by optimizing viral load suppression) and individual clients’ overall health, quality of life, and wellness needs are thoroughly addressed.
ADAPs are a component part of the Part B program charged with ensuring access to lifesaving treatments for HIV, notably antiretroviral (ARV) and “A1” opportunistic infection medications, as well as those for comorbid conditions that disproportionately impact PLWHA and/or affect the adherence to or effectiveness of ARV treatment. ADAPs do so through two mechanisms: (1) by paying for any client medications on the program’s formulary; and (2) by paying for a portion or all of a client’s premiums and cost sharing (including deductibles, copayments, and coinsurance costs) for private or public insurance that includes prescription drug coverage.
The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act enables ADAPs to cover a broad array of medications within their formularies for insured and uninsured clients with a limited number of requirements (e.g., all medications and ancillary devices be U.S. Food and Drug Administration [FDA]-approved). ADAPs’ expansive coverage is critical to their success and consistent with overall goals of the RWHAP to meet the comprehensive medication needs of PLWHA, including those aging with HIV/AIDS, substance use treatments, and gender-affirming hormone therapy.
Ending the HIV Epidemic (EHE) Initiative
In February 2019, the White House administration announced Ending the HIV Epidemic: A Plan for America (EHE), which remains the federal government’s plan to end the HIV epidemic by 2030. The plan’s goals are to reduce new HIV infections by 75% by 2025 and 90% by 2030. EHE will be focused on four pillars: (1) diagnose all PLWHA as early as possible; (2) treat PLWHA rapidly and effectively to reach sustained viral suppression; (3) prevent new HIV transmission by using proven interventions, including pre-exposure prophylaxis (PrEP) and syringe services programs (SSPs); and (4) respond urgently to HIV clusters and potential outbreaks to get needed prevention and treatment services to the communities who need them.
As a part of EHE initiative, Phase 1 jurisdictions were required to develop EHE plans focusing on the four pillars. Even before the EHE initiative was announced in 2019, many cities, counties, and states had already developed, or were in the process of developing, EHE plans in their jurisdiction. These plans, which were often community-led, continue to be dynamic and can be accessed via NASTAD’s jurisdictional interactive map of EHE plans.
RWHAP Part B programs and ADAPs are critical to jurisdictional and national EHE efforts at all levels, including the federal EHE initiative, by providing broad and person-centered services to meet the needs of all PLWHA. They are also integral to “undetectable = untransmittable (U=U)”, an evidenced-based campaign about the fact that PLWHA who are on ARV therapy and durably virally suppressed (i.e., viral load ≤ 200 copies/mL) cannot sexually transmit HIV.