HIV and AIDS Data through December 2019 Provided for the Ryan White HIV/AIDS Program, for Fiscal Year 2021: Commentary

The Ryan White HIV/AIDS Program (RWHAP) is administered by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed by Congress in 1990 to address the crisis of the HIV epidemic in the United States. This legislation has been amended and reauthorized 4 times: in 1996, 2000, 2006, and most recently in 2009 as the Ryan White HIV/AIDS Treatment Extension Act of 2009. More information about the legislation and its history is available from HRSA HAB at https://hab.hrsa.gov/about-ryan-white-hivaids-program/external icon.

For the implementation of the RWHAP Metropolitan (Part A) and State (Part B) programs, HRSA HAB and the Centers for Disease Control and Prevention (CDC) collaborate to ensure the appropriate HIV and AIDS surveillance data are used in determining eligibility and funding allocation amounts. In FY 2021, HRSA used total counts of persons living with diagnosed HIV infection non-AIDS and persons living with infection ever classified as AIDS to calculate funding allocation amounts for eligible jurisdictions. For FY 2021, CDC provided HRSA with data files containing this information through calendar year 2019 for all jurisdictions. The number of persons living with diagnosed HIV infection non-AIDS and the number of persons living with infection ever classified as AIDS were added together to arrive at the total number of persons living with diagnosed HIV infection non-AIDS and infection ever classified as AIDS for each eligible area: eligible metropolitan area (EMA), transitional grant area (TGA), emerging community (EC), state, and territory. These totals were used in the RWHAP Parts A and B funding formula calculations.

RWHAP Part A Funding

For the RWHAP Part A funding formula, HRSA continues to use cumulative cases of AIDS reported to and confirmed by the Director of CDC for the most recent 5 calendar years for which such data are available to determine eligibility, as instructed by the RWHAP statute. RWHAP Part A has 2 categories of grant recipients for areas that have a minimum population of 50,000 persons: EMAs and TGAs. EMAs are defined as areas that have a cumulative total of more than 2,000 AIDS cases reported to and confirmed by the Director of CDC during the most recent 5 calendar years for which such data are available. An area will continue to be an EMA unless it fails to meet both of the following requirements for 3 consecutive fiscal years: (a) a cumulative total of more than 2,000 AIDS cases reported to and confirmed by the Director of CDC during the most recent period of 5 calendar years for which such data are available, and (b) a cumulative total of 3,000 or more persons living with HIV infection ever classified as AIDS reported to and confirmed by the Director of CDC as of December 31 of the most recent calendar year for which such data are available. In FY 2021, there were 24 EMAs.

TGAs, the other category of Part A recipients, are defined as areas that have a cumulative total of at least 1,000 but fewer than 2,000 AIDS cases reported to and confirmed by the Director of CDC during the most recent 5 calendar years for which such data are available. An area will remain a TGA unless it fails to meet both of the following requirements for 3 consecutive fiscal years: (a) a cumulative total of at least 1,000 but fewer than 2,000 cases of AIDS reported to and confirmed by the Director of CDC during the most recent period of 5 calendar years for which such data are available, and (b) a cumulative total of 1,500 or more persons living with HIV infection ever classified as AIDS reported to and confirmed by the Director of CDC as of December 31 of the most recent calendar year for which such data are available. Provisions in the RWHAP statute provided for a modification beginning in FY 2009: in the case where a metropolitan area has a cumulative total of at least 1,400 but fewer than 1,500 persons living with HIV infection ever classified as AIDS as of December 31 of the most recent calendar year for which such data are available, such area shall be treated as having met criterion (b) as long as the area did not have more than 5% unobligated balance as of the most recent fiscal year for which such data are available. Areas that have fallen below either or both of the required TGA thresholds, but that continue to be eligible per the RWHAP statute because they must fail both criteria for three consecutive years, remain designated as TGAs and are presented in the TGA tables. For FY 2021, there were 28 TGAs.

The geographic boundaries for all jurisdictions that received Part A funding in FY 2021—both EMAs and TGAs—are those metropolitan statistical area (MSA) boundaries determined by the Office of Management and Budget (OMB) for use in federal statistical activities that were in effect when they were initially funded under Part A [1–3]. For all newly eligible areas, of which there were none in FY 2021, the boundaries are based on current MSA boundary definitions determined by OMB [1–3].

Minority AIDS Initiative (MAI) formula funds for Part A are awarded based on the reported number of minority persons living with diagnosed HIV infection, non-AIDS and infection ever classified as AIDS reported through the end of the most recent calendar year as confirmed by the Director of CDC. Data for MAI formula funds are not included in this report.

RWHAP Part B Funding

RWHAP Part B and AIDS Drug Assistance Program (ADAP) funds are awarded via 3 separate grant award processes: the RWHAP Part B HIV Care Program award, the RWHAP Part B Supplemental Grant Program award, and the RWHAP Part B ADAP Emergency Relief Fund (ERF) award. The RWHAP Part B HIV Care Program award has a 5-year project period and is determined by a legislatively mandated funding formula process. The award includes the following 5 components: Part B Base award, ADAP Base award, ADAP Supplemental award (for eligible states that choose to apply), Emerging Communities award (for eligible states), and MAI award (for eligible states that do not decline funding). The RWHAP Part B Supplemental grant is a one-year competitive award for states that demonstrate the need for additional RWHAP Part B funds. The ADAP ERF grant is also a one-year competitive award. These funds are used to help states prevent, reduce, or eliminate ADAP waiting lists and/or to implement ADAP-related cost-containment measures.

RWHAP Part B HIV Care Program Grant

For the RWHAP Part B Base, ADAP Base, ADAP Supplemental, Emerging Communities, and MAI funding formulas, HRSA continues to use cumulative cases of persons living with diagnosed HIV infection non-AIDS and infection ever classified as AIDS in the state or territory through the end of the most recent calendar year as confirmed by the Director of CDC, as instructed by the RWHAP statute. The RWHAP Part B Base formula is a weighted relative distribution that also takes into account RWHAP Part A funding. Similarly, for recipients applying for MAI formula funds, awards are based on the reported number of racial/ethnic minorities living with diagnosed HIV infection non-AIDS and infection ever classified as AIDS reported through the end of the most recent calendar year as confirmed by the Director of CDC. Data for MAI formula funds are not included in this report. ADAP Supplemental grants are awarded by the same formula as ADAP Base to states that meet any of the criteria listed in that section of the Notice of Funding Opportunity for the purpose of providing medications or insurance assistance for persons living with HIV infection.

RWHAP Part B Emerging Communities eligibility is determined based on the number of persons living with HIV infection ever classified as AIDS in that jurisdiction. Emerging communities are defined as metropolitan areas for which there have been at least 500 but fewer than 1,000 AIDS cases reported to and confirmed by the Director of CDC during the most recent 5 calendar years for which such data are available. An area will remain an emerging community unless it fails to meet both of the following requirements for 3 consecutive fiscal years: (a) a cumulative total of at least 500 but fewer than 1,000 cases of AIDS reported to and confirmed by the Director of CDC during the most recent period of 5 calendar years for which such data are available, and (b) a cumulative total of 750 or more persons living with HIV infection ever classified as AIDS reported to and confirmed by the Director of CDC as of December 31 of the most recent year for which such data are available. As with EMAs and TGAs, the geographic boundaries for emerging communities are those that were determined by OMB and that were in effect when initially funded.

RWHAP Part B Supplemental and ADAP ERF Grants

RWHAP Part B Supplemental and ADAP ERF grants are awarded to states demonstrating the severity of the burden of HIV infection and the need for additional federal assistance. The funds are intended to supplement the services otherwise provided by the state. All submitted applications for RWHAP Part B Supplemental and ADAP ERF competitive grants are reviewed and ranked by an external objective review committee. States and territories applying for RWHAP Part B Supplemental funds must demonstrate that supplemental funding is necessary to provide comprehensive HIV care and treatment services for persons living with HIV in the state or territory, and provide quantifiable data on HIV epidemiology, comorbidities, cost of care, the service needs of emerging populations, unmet need for core medical services, and unique service delivery challenges. States and territories applying for RWHAP ADAP ERF funds must demonstrate the need for funding to prevent, reduce, or eliminate a waiting list, including through “cost-cutting” and/or “cost-saving” measures, or that need additional funding for a current or projected increase in treatment needs aligned with ending the HIV epidemic or other unanticipated increases in the number of clients in the program who have newly diagnosed HIV infection or have reengaged in care.