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Center for Substance Abuse Treatment. Treatment for HIV-Infected Alcohol and Other Drug Abusers. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1995. (Treatment Improvement Protocol (TIP) Series, No. 15.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Treatment for HIV-Infected Alcohol and Other Drug Abusers

Treatment for HIV-Infected Alcohol and Other Drug Abusers.

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Appendix E - Information About the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (The CARE Act)1

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 represents the largest dollar investment made by the Federal Government to date specifically for the provision of services for people with human immunodeficiency virus (HIV) infection. The purpose of the act is "to improve the quality and availability of care for individuals and families with HIV disease."

The act directs assistance to:

  • Metropolitan areas with the largest number of reported cases of acquired immunodeficiency syndrome (AIDS) to meet emergency service needs (Title I)
  • All States to improve the quality, availability, and organization of healthcare and support services for individuals with HIV disease and their families (Title II)
  • All States to support early intervention services (Title III)
  • Support a series of specified general provisions including evaluations and reports, as well as research and services for pediatric patients (Title IV).
  • The appropriations for Titles I, II, and III of the CARE Act were as follows:
  • Fiscal Year 1991 $220.5 million
  • Fiscal Year 1992 $279.3 million
  • Fiscal Year 1993 $348.1 million
  • Fiscal Year 1994 $579.4 million.

Title IV did not receive funding until Fiscal Year (FY) 1994. Total appropriations for Titles I, II, III, and IV in FY 94 was $658.1 million.

The Health Resources and Services Administration (HRSA) has lead responsibility for the CARE Act. Its Bureau of Health Resources Development (BHRD) manages Titles I and II, the Bureau of Primary Health Care (BPHC) is responsible for Title III(b), and the Maternal and Child Health Bureau (MCHB) is responsible for Title IV.

Title I: Emergency Relief Grants to Eligible Metropolitan Areas (EMAs)

Purpose: To provide emergency assistance to localities that are disproportionately affected by the HIV epidemic.

Eligible grantees: For FY 91, metropolitan areas reporting a total of more than 2,000 cases of AIDS to the Centers for Disease Control (CDC) by June 30, 1990, or in which the per capita incidence of cumulative cases of AIDS is not less than 0.0025. For subsequent fiscal year funding, the same criteria apply for total cases or incidence reported as of March 31 of the most recent fiscal year (i.e., for FY 94 funding, data reported as of March 1993).

As of December 1, 1994, 42 EMAs are eligible.

Administration: Grants are awarded to the Chief Elected Official (CEO) of the city or urban county that administers the public health agency providing outpatient and ambulatory services to the greatest number of people with AIDS in the area eligible for the grant.

There are two major administrative requirements:

  1. The CEO must have an intergovernmental agreement with any area political subdivision that provides HIV-related health services and in which at least 10 percent of the EMA's AIDS cases were diagnosed. That agreement establishes an administrative mechanism to allocate funds and services.
  2. The CEO must establish a new entity or designate an existing one to serve as an HIV Health Services Planning Council (HHSPC). The designated entity should have experience in planning for the HIV healthcare needs within the EMA. The CARE Act requires that this entity or council establish priorities for HIV care delivery.

The HHSPC must include, at a minimum, representatives from 11 specific groups:

  • Healthcare providers
  • Community-based and AIDS service organizations
  • Social services providers
  • Mental healthcare providers
  • Local public health agencies
  • Hospital planning agencies or healthcare planning agencies
  • Affected communities, including individuals with HIV disease
  • Nonelected community leaders
  • State government
  • Entities receiving grants under Title II of the act (early intervention)
  • The lead agency of any HRSA demonstration grant.
  • The HHSPC must
  • Establish priorities for allocating funds within the EMA
  • Develop a comprehensive plan for the organization and delivery of HIV health services that is compatible with existing State or local plans
  • Assess the efficiency of the administrative mechanisms to rapidly allocate funds to areas of greatest need.

Use of grants: The EMA must agree to distribute grant funds according to the priorities established by the HHSPC. Grant funds are to be used for delivering or enhancing HIV-related

  • Outpatient and ambulatory health and support services, including case management and comprehensive treatment services
  • Inpatient case management services that expedite discharge.

The EMA may make awards to public or nonprofit entities, including hospitals (including Veterans Affairs facilities), community-based organizations, hospices, ambulatory care facilities, community health centers, migrant health centers, and homeless health centers.

Title II: HIV Care Grants to the States

Purpose: To enable States to improve the quality, availability, and organization of healthcare and support services for individuals with HIV disease and their families.

Eligible grantees: Each State, the District of Columbia, Puerto Rico, and the territories are eligible for funds, based on the number of AIDS cases diagnosed and reported to CDC for the 2 most recent fiscal years, and the average per capita income of State/U.S. population. The minimum grant amount will be $100,000.00.

Use of grants:

  • To establish and operate HIV care consortia designed to provide a comprehensive continuum of care to individuals with HIV disease and their families. States reporting 1 percent or more of the total number of AIDS cases reported nationally are required to use at least 50 percent of their CARE grant to create and operate consortia in those areas of the State with the largest number of individuals with HIV disease.
  • To provide home and community-based care services for individuals with HIV disease.
  • To provide assistance to ensure the continuity of health insurance coverage for persons with HIV disease.
  • To provide treatments to prolong life or prevent serious deterioration of health to individuals with HIV disease.

In addition, the act requires that 15 percent of grant funds be set aside to provide health and support services to infants, children, women, and families with HIV disease.

HRSA may use up to 10 percent of the total funds appropriated for Title II to make competitive grant awards for Special Projects of National Significance (SPNS). SPNS programs are to assess innovative and replicable models of care and treatment for individuals with HIV.

HIV Care Consortia

Definition: An association of one or more public and one or more nonprofit private, healthcare, and support services providers, and community-based organizations. These must operate within areas determined by the State to be most affected by HIV disease. The association agrees to use grant assistance to plan, develop, and deliver (directly or through agreements with others) comprehensive outpatient health and support services for individuals with HIV disease. These services may include:

  • Essential health services: case management; medical, nursing and dental care; diagnostics; monitoring and medical followup services; mental health, developmental, and rehabilitation services; and home health and hospice care
  • Essential support services: transportation, attendant care, homemaker services, day or respite care, benefits (e.g., health, disability, etc.) advocacy, advocacy services provided through public and nonprofit private entities, nutrition services, housing referral services, child welfare and family services (including foster care and adoption services), and counseling on living with HIV.

States are to give priority in funding first to consortia receiving assistance from HRSA for adult/pediatric HIV-related care demonstration projects, then to any other existing HIV care consortia.

Home and Community-Based Care

Definition: With respect to an individual with HIV disease, skilled health services are furnished in the individual's home under a written plan of care established by a case management team. The plan includes appropriate healthcare professionals and the following services and items:

  • Durable medical equipment
  • Homemaker or home health aide services and personal care services provided in the home
  • Day treatment or other partial hospitalization services
  • Home intravenous and aerosolized drug therapy
  • Routine diagnostic testing
  • Appropriate mental health, developmental, and rehabilitation services.

Funds received may not be used for services in an inpatient hospital, nursing home, or other long-term care facilities.

States may make grant awards under this section of the law to entities providing outreach services to

  • Help individuals with HIV disease (including rural residents)
  • Coordinate home and community-based care with other HIV-related health services provided by public and private entities.

In making grant awards, States will give priority to entities participating in HIV care consortia and those that will use home and community-based funds for low-income individuals with HIV disease.

Health Insurance Coverage

States may use grant funds to establish a program of financial assistance for low-income individuals with HIV disease who meet eligibility criteria. The funds will allow these individuals to either maintain continuity of their existing health insurance coverage or to receive medical benefits under another health insurance program, including risk pools.

States may not use these funds to pay for creating or administering a liability risk pool or to pay any amount expended by the State under Medicaid.

Provision of Treatments

States may use funds under this section to establish a program to provide treatment for individuals eligible to participate, that is determined to prolong life or prevent the serious deterioration of health arising from HIV disease. Eligible individuals must have a medical diagnosis of HIV and be a low-income individual as defined by the State. The State shall determine which treatments are eligible to be included, in accordance with guidelines issued by the Secretary, Department of Health and Human Services (DHHS).

Matching funds: States with more than 1 percent of AIDS cases reported nationally in the previous 2 years must make available (either in cash or in-kind contributions -- including donations from public or private entities) resources to match Federal funds awarded under Title II. (The law specifically excludes Puerto Rico from this requirement.) This matching requirement is by formula as follows:

  • 1991 - $1 State for every $5 Federal
  • 1992 - $1 State for every $4 Federal
  • 1993 - $1 State for every $3 Federal
  • 1994 - $1 State for every $2 Federal
  • 1995 - $1 State for every $2 Federal.

Special Projects of National Significance (SPNS)

(Title II of the CARE Act)

Purpose: SPNS programs are to contribute to the advancement of knowledge and skills in the delivery of health and support services to persons with HIV disease.

Eligible grantees: Any public or private nonprofit organization, including community-based organizations. Grants are usually awarded for 3-year cycles.

Use of grants: Up to 10 percent of Title II funds may be set aside for SPNS grants. SPNS programs must

  • Evaluate the effectiveness of a program model
  • Appraise the innovative qualities of a model's activities
  • Determine the potential replicability of the model in other similar localities or nationally.

Each year the SPNS program examines the dilemmas confronting HIV service providers to determine what issues should be addressed through demonstration and evaluation projects. In 1991 and 1992, the first 2 years of funding, priority was given to projects that would

  • Demonstrate improved access to care through reduction of social, financial, and transportation barriers experienced by one of these five special population groups with HIV: rural residents; women, children and/or adolescents; incarcerated persons; recently released inmates; and American Indians/Alaska Natives
  • Demonstrate models of advocacy on behalf of persons infected with HIV that assure timely receipt of adequate health and support services
  • Reduce social isolation of people with HIV in order to improve their quality of life
  • Integrate mental health services into primary care sites.

In FY 93, a fifth priority was added that focused on the unique problems of identifying and caring for adolescents who were infected with or affected by HIV.

Title III(b): Early Intervention Services

Prevention: To support early intervention HIV services (EIS) for people with AIDS and HIV infection.

Eligible grantees: Organizations that are eligible to apply for Title III(b) funds include public or nonprofit private entities currently providing comprehensive primary care services to populations at risk for HIV infection, and the following other entities:

  • Migrant health centers receiving support under sections 329 of the PHS Act
  • Community Health Centers receiving support under sections 330 of the PHS Act
  • Healthcare for the Homeless centers receiving support under sections 340 of the PHS Act
  • Family Planning grantees (other than States) receiving support under section 1001 of the PHS Act
  • Comprehensive Hemophilia Diagnostic and Treatment Centers
  • Federally qualified health centers supported under section 1905(1)(2)(b) of the Social Security Act.

Use of grants: The early intervention program must provide a continuum of HIV services including

  • HIV risk reduction counseling and testing
  • Partner involvement strategies for HIV risk reduction
  • Transmission prevention
  • Counseling and education on living with HIV disease
  • Appropriate medical evaluation and clinical care (such as CD4 monitoring; antirotroviral therapy; diagnosis, prophylaxis, and treatment of opportunistic infections, including TB; and malignancies)
  • A plan for managing the coepidemics of tuberculosis and substance abuse
  • Referrals.

The applicant may also provide optional services such as

  • A program of outreach that will explain the benefits of early intervention to those who may have HIV disease or who may be at high risk for contracting the disease
  • A program of outreach to providers to make them aware of the availability and benefits of EIS services
  • A program providing assistance to individuals in establishing eligibility for financial assistance and services under Federal, State, or local programs that provide health services, mental health services, social services, or other appropriate services
  • A program to provide case management to persons infected with HIV.

Title IV: General Provisions, Reports, and Evaluation

HIV Demonstration Program for Children, Adolescents, and Families

In FY 1994, Congress transferred the Pediatric/Family AIDS Demonstration Program to Title IV of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. The program will be permanently authorized in Section 1071 of the Public Health Service Act. As a result of this transfer to Title IV, the focus of the program is further expanded to develop innovative models that link systems of comprehensive primary/community-based medical and social services for the affected population with National Institutes of Health (NIH) and other clinical research trials.

Other sections of this title were not funded in FY 1994, but a summary of some of the title's authorities is provided below.

Research, Evaluation, and Assessment Program

Purpose: The Agency for Health Care Policy and Research shall establish a grant program of independent research to develop

  • A comparative assessment of the impact and cost- effectiveness of major models for organizing and delivering HIV-related healthcare, mental healthcare, early intervention, and support services that report on patient outcomes, satisfaction, perceived quality of care, and total cumulative cost
  • An assessment of strategies for maintaining private health benefits for individuals with HIV disease and an assessment of specific business practices and regulatory barriers that could reduce access to private-sector benefits programs
  • An assessment of the manner in which different points of entry to the healthcare system affect the cost, quality, and outcome of the care and treatment of individuals and families with HIV disease
  • A summary report concerning the major and continuing unmet needs in healthcare, mental health, early intervention and support services for individuals and families with HIV disease, in both urban and rural areas.

Eligible grantees: Individuals and organizations with appropriate expertise in the fields of health, health policy, and economics (particularly healthcare economics).

Research and Services for Pediatric Patients With HIV

Purpose: The Health Resources and Services Administration and the National Institutes of Health shall make grants to conduct clinical research on therapies for pediatric patients with HIV disease and pregnant women with HIV, and to provide healthcare to the pediatric patients and their families.

Eligible grantees: Community health centers and other appropriate public or nonprofit private entities that provide primary care and serve a significant number of pediatric patients and pregnant women with HIV disease.

Study Regarding Partner Notification

Purpose: The Secretary of DHHS shall conduct a study of programs of HIV partner notification to determine

  • In the case of individuals who have been notified under such programs, the percentage of such individuals who undergo HIV counseling and testing
  • The number of such individuals having HIV disease
  • The extent to which such programs have resulted in behavioral changes that are effective regarding the prevention of exposure to and transmission of HIV disease
  • The extent to which such programs represent a cost-effective use of available HIV-related resources.

Study Regarding HIV Disease in Rural Areas

Purpose: The Secretary of DHHS, in consultation with the Director of the Office of Rural Health Policy, shall

  • Conduct a study to estimate the incidence and prevalence in rural areas of AIDS cases and cases of infection with the etiologic agent for such syndrome
  • Determine the adequacy of services for diagnosing and treating early-stage HIV infection.


This summary was adapted from information provided by the Bureau of Health Resources Development, Health Resources and Services Administration, Public Health Service, U.S. Department of Health. For more information about the act, including a list of State grantees, contact the office of Eric P. Goosby, M.D., Director, Division of HIV Services, 5600 Fishers Lane, Room 7A-55, Rockville, Maryland 20857; (301) 443-6745.

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