The U.S. House of Representatives debated the Ryan White CARE Act for approximately 40 minutes before a unanimous consent voice vote reauthorized AIDS services for five more years.
The vote came shortly after midnight in the first few minutes of July 26. The Senate passed a similar measure June 6. The bills contain differences, both minor and significant, that will have to be worked out in conference, likely in September.
"We are grateful that members of both parties recognized the importance of reauthorizing this successful program," said Claudia French, acting executive director of the AIDS Action Council. She singled out lead the sponsors, conservative Tom Coburn., R-Okla., and liberal Henry Waxman, D-Calif., for special praise.
Winnie Stachelberg, political director of the Human Rights Campaign ( HRC ) , joined in the praise. She called on Congress and the administration to resolve differences between the two bills before Congress adjourns.
One of the principal differences is the "hold harmless" provision in the formula for distributing federal money. It limits how much any jurisdiction may lose as money is redistributed to meet changing demographics of the HIV epidemic. The Senate version limits it to 2 percent a year with a cap of 10 percent over the five-year life of the program. The House version has staggered losses that start at 2 percent and grow over time to allow a cumulative loss of up to 25 percent of funding.
"At the present time it appears that only the San Francisco area would be affected" by the House version, said Terje Anderson, executive director of the National Association of People With AIDS ( NAPWA ) . But that may change, other jurisdictions may be affected as new surveillance data becomes available based upon HIV reporting rather than AIDS reporting.
"We are providing care based on HIV" serostatus and not an AIDS defined diagnosis, said Anderson, so using AIDS data alone is inadequate.
"But it is not clear that [ an ] HIV [ definition ] is a whole lot better," Anderson said. At least AIDS measures those who need services, while an HIV system measures only those who "are aware enough of their risk to come forward for testing." It says nothing about their need for services, which may be minimal or great.
"San Francisco suffers because they are a first wave city that got hit early in the epidemic," said Anderson. "As this epidemic has grown in the rest of the country, their percentage, but not their raw numbers, has shrunk. And that is what the formula is based on."
"The second reason that they suffer is because they have public health systems that work. People in San Francisco are getting into care fairly effectively, and that means that they are less likely to get diagnosed with AIDS," he said. "Nobody is getting too much money, there is unmet need out there."
The fear that some cities may receive less money disappears if funding for the entire Ryan White programs is increased sufficiently. Another factor that seems likely to ease financial pressures over the five years of the program is the likely widespread introduction of structured interruptions of therapy. That will reduce the amount of drugs used by each patient and their total cost to programs such as ADAP.
