HIV and Stage 3 (AIDS) Classifications Data through December 2021 Provided for the Ryan White HIV/AIDS Program, for Fiscal Year 2023: 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 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 at https://ryanwhite.hrsa.gov/about/legislation.

For the implementation of the RWHAP Metropolitan (Part A) and State (Part B) programs, HRSA and the CDC collaborate to ensure the appropriate HIV surveillance data are used in determining eligibility and funding allocation amounts. In FY 2023, HRSA used total counts of persons living with diagnosed HIV infection non-stage 3 (AIDS) and persons living with infection ever classified as stage 3 (AIDS) to calculate funding allocation amounts for eligible jurisdictions. For FY 2023, CDC provided HRSA with data files containing this information through calendar year 2021 for all jurisdictions. The number of persons living with diagnosed HIV infection non-stage 3 (AIDS) and the number of persons living with infection ever classified as stage 3 (AIDS) were added together to arrive at the total number of persons living with diagnosed HIV infection non-stage 3 (AIDS) and infection ever classified as stage 3 (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 calculations for determining formula funding amounts.

RWHAP Part A Funding

Part A Eligibility

To determine eligibility for RWHAP Part A formula funding, HRSA continues to use cumulative stage 3 (AIDS) classifications reported to and confirmed by the Director of CDC for the most recent five calendar years for which such data are available, as instructed by the RWHAP statute. RWHAP Part A awards grants to Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) that have a minimum population of 50,000 persons.

EMAs are defined as areas that have a cumulative total of more than 2,000 stage 3 (AIDS) classifications reported to and confirmed by the Director of CDC during the most recent five 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 three consecutive fiscal years: (a) a cumulative total of more than 2,000 stage 3 (AIDS) classifications reported to and confirmed by the Director of CDC during the most recent period of five 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 stage 3 (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 2023, there were 24 EMAs.

TGAs are defined as areas that have a cumulative total of at least 1,000 but fewer than 2,000 stage 3 (AIDS) classifications reported to and confirmed by the Director of CDC during the most recent five 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 three consecutive fiscal years: (a) a cumulative total of at least 1,000 but fewer than 2,000 stage 3 (AIDS) classifications reported to and confirmed by the Director of CDC during the most recent period of five 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 stage 3 (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 included 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 stage 3 (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 of RWHAP funds as of the most recent fiscal year for which such data are available. Areas that have fallen below either or both 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 2023, there were 28 TGAs.

The geographic boundaries for all jurisdictions that received RWHAP Part A funding in FY 2023—both EMAs and TGAs—are 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 RWHAP Part A [1–3]. For all newly eligible areas, of which there were none in FY 2023, the boundaries are based on current MSA boundary definitions determined by OMB [1–3].

Part A Funding

To determine formula funding amounts as instructed by the RWHAP statute, HRSA continues to use cumulative cases of persons living with diagnosed HIV infection non-stage 3 (AIDS) and infection ever classified as stage 3 (AIDS) in the EMA or TGA through the end of the most recent calendar year as confirmed by the Director of CDC. The RWHAP Part A formula is a weighted relative distribution.

Minority AIDS Initiative (MAI) formula funds for RWHAP Part A are awarded based on the reported number of minority persons living with diagnosed HIV infection non-stage 3 (AIDS) and infection ever classified as stage 3 (AIDS) reported through the end of the most recent calendar year as confirmed by the Director of CDC. Data used to determine MAI formula funding amounts are not included in this report.

RWHAP Part B Funding

RWHAP Part B and AIDS Drug Assistance Program (ADAP) funds are awarded by three 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 five-year project period and is determined by a legislatively mandated process to fund formula-based awards. The award includes the following five 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 Funding

To determine formula funding amounts for the RWHAP Part B Base, ADAP Base, ADAP Supplemental, Emerging Communities, and MAI as instructed by the RWHAP statute, HRSA continues to use cumulative cases of persons living with diagnosed HIV infection non-stage 3 (AIDS) and infection ever classified as stage 3 (AIDS) in the state or territory through the end of the most recent calendar year as confirmed by the Director of CDC. The RWHAP Part B Base formula is a weighted relative distribution that takes into account RWHAP Part A funding. The remaining funding streams are based on a relative distribution. 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 with HIV.

Emerging Communities Eligibility

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

For recipients applying for MAI formula funds, awards are based on the reported number of racial/ethnic minorities living with diagnosed HIV infection non-stage 3 (AIDS) and infection ever classified as stage 3 (AIDS) reported through the end of the most recent calendar year as confirmed by the Director of CDC. Data used to determine MAI formula funding amounts are not included in this report.

RWHAP Part B Supplemental and ADAP ERF Funding

RWHAP Part B Supplemental and ADAP ERF grants are awarded to states demonstrating the severity of the burden of HIV 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 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 the need for 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.