Update on the Use of the Ryan White Modernization Act 2006 and Formerly Incarcerated Persons: Will Grantees Be Prepared

Earlier this month, I wrote an article titled “Ryan White HIV/AIDS Treatment Modernization Act: Does It Synchronize with the Needs of Urban America” which suggested that the needs of the incarcerated, particularly those affected by HIV, black and male are disenfranchised. “Urban America” within the context of this article is defined as the current state of public policy in urban areas. There is a consensus that policy settings from 1960’s and the 1970’s have brought major progress in terms of segregation. In contrast to the 1980’s, there appears to be a retreat to anti-poverty policies (10). The correlation of existing policy settings compared to the inferences drawn from the scope of the Minority AIDS Initiative (MAI) and the Ryan White HIV/AIDS Treatment Modernization Act of 2006, have led to presumptions that suggest a significant shortcoming of meeting the needs of Urban America; due to the complexity of funding parameters, lack of qualified grantees at the local level and inadequate work flow processes which indicate how vital information is shared at the state and local level (11, 12).

“Most Ryan White clients are of low-income, underinsured and of ethnic backgrounds. But as trends become more complex in Blacks, particularly those in prison, on probation and others who fall through the cracks…efforts to capture this cohort appear to be lost in translation in comparison to the new Part A formularies. This is evidenced by the scope of funding parameters for the EMA’s and validation of Community Resource Guides (6, 7, and 8) from three cities. There also appears to be a lack of acknowledgement of Blacks in prison or probation, as it relates to HIV epidemiology and the correlation to Part A funding (2).”
On September 28, 2007 the Health Resources and Services Administration (HRSA) and HIV/AIDS Bureau published an update (Policy Notice -07-04) “The Use of Ryan White HIV/AIDS Program Funds for Transitional Social Support and Primary Care Services for Incarcerated Persons.” According to the notice, the updated policy reflects the changes in Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Program (1). What drove the changes in policy to expand care to incarcerated persons?

One can speculate that recent data provided by the Bureau of Justice Statistics (BJS) may have prompted immediate attention by respective state health departments. BJS provides the number of HIV-infection and confirmed AIDS case among State and Federal prisoners. This is accomplished annually via bulletin reports, which are distributed presumably to parties of interest. Based on this observation, it appears there may be a lack of transparency at the state and local levels of how vital statistical information is shared with appropriate shareholders at the local level. As a result, questions have been raised about what is being done with the information as it relates public health policy and subsequent funding schemes with respect to Ryan White regions. “Until this fete is acknowledged and accomplished, MAI’s portfolio may yield less than a satisfactory outcome on incidence rates of HIV/AIDS in African American women in urban settings, until this correlation is further substantiated (2).”

According to the Office of the Assistant Surgeon General, the intent of the Ryan White HIV/AIDS Program is to ensure that “eligible” HIV infected persons gain or maintain access to HIV-related care and treatment (1).” The word “intent” implies a desire to act or plan or the failure to achieve a stated objective. In the case of HRSA, one can infer from the update, a late acknowledgment by the federal government to take appropriate measures may be considered disingenuous. According to the update, the updated policy “supports” the use of Ryan White HIV/AIDS Program funds for incarcerated and formerly incarcerated persons. This “new” position further validates a previous observation communicated in “Ryan White HIV/AIDS Treatment Modernization Act: Does It Synchronize with the Needs of Urban America” that funding parameters were not transparent at the local level in regards to this cohort, due to the ambiguous language offered in Title XXVI of the Public Health Service Act. Moreover, funding from Ryan White Program was either complacent or simply not available previous to this update in public health law, due to scarce resources $303, 113, 785 (Total 2007 Part A Formula Funds) for all eligible EMA’s. In addition, there was no process in place to bring local grantees into the picture, because the scope of the funding mechanism was not established prior to September 2007. As a result, prospective grantees may face challenges which include:

• The lack of training tools for grantees to adapt their respective practice for formerly incarcerated persons.
• Conflict of interest may arise between grantees and respective infirmary command centers concerning coordination and/or replication of primary care services. Further, teasing out non-covered services should not be the responsibility of the grantee. HRSA should take a more proactive approach.
• The policy update does not address the relationship that grantees must be cultivate with the Department of Probation, as it relates to their clients, caseloads and work flow processes. This observation should be applied to formerly incarcerated individuals who reside in pre-release and other community settings.
• Transitioning social services of formerly incarcerated individuals is a challenging opportunity. The potential of conflict of interest may arise with other agencies. Including, the Department of Corrections, Department of Probation and the local Health and Human Services agencies. Grantees must recognize these relationships and how offered services create additional synergies for its prospective clients.
• With respect to developing communication standards with respect to this unique clientele: grantees should consult with the Office of Human Research Protections (OHRP) with regards to prisoners and those who are formerly incarcerated. Incidentally, these standards are applicable to conducting research, the applicability of 45 CFR 46 [DHHS: Protection of human subjects]; 21 CFR 50 [FDA: informed consent] and 21 CFR 56 [FDA: IRB review and approval] (9) (should be succinctly integrated within the scope of the grantee’s proposal.
• It may also be the responsibility of the HRSA to provide additional training with regard to data collection and reporting. According to the U.S. Department of Justice Statistics, Office of Justice Programs funding recipients are required to comply with Federal requirements concerning human subject research and confidentiality of information. Protection of Human Subjects and Privacy Certificate Requirements may be required.

Based on the total 2007 Part A outlays of $303, 113, 785 it appears that meeting the operational scope defined with Policy Notice-07-04 will be challenging for grantees and other stakeholders who have an interest in serving this unique population.
HIV/AIDS Bureau has defined nine criteria in which funding eligibility may be quantified. In the opinion of this advisory board, Transitional Primary Care Services, Transitional Social Services and Reporting may prove to be the most critical benchmarks in terms of quantifying the success during program’s lifecycle.

References
1. Health Resources and Services Administration. (2007). Policy Notice-07-04, the Use of Ryan White HIV/AIDS Program Funds for Transitional Social Support and Primary Care Services for Incarcerated Persons. Retrieved from http://hab.hrsa.gov/law/0704.htm on October 22, 2007.

2. Jacquescoley, E. (2007). Does current Ryan White HIV/AIDS treatment provisions line up with urban needs? Retrieved from http://www.helium.com/tm/629671/white-hivaids-treatment-modernization on October 22, 2007.

3.Centers for Disease Control and Prevention. [Online]. Deaths of Persons with AIDS. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/basic.htm#ddaids on October
4, 2007.

4. Centers for Disease Control and Prevention. [Online]. HIV/AIDS in 2005. Retrieved from http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm on October 4, 2007.

5. Health Resources Services Administration. [Online]. Ryan White Care Act. Retrieved from http://hab.hrsa.gov/programs/CareActOverview/ on October 4, 2007.

6. Ohio Board of County Commissioners. [Online]. Community Resource Guide: To Medical and Social Services Available To Persons Living With HIV/AIDS in Northeast Ohio. Retrieved from http://ryanwhite.cuyahogacounty.us/services.htm on October 4, 2007.

7. www.miamidade.gov [Online]. Miami Dade County-Ryan White. Retrieved from http://www.google.com/search?sourceid=navclient&aq=t&ie=UTF-8&rls=GGLF,GGLF:1969-53,GGLF:en&q=Ryan+White+Part+A on October 4, 2007.

8. Boston Public Health Department. [Online]. Boston Public Health Commission AIDS Program. Retrieved from http://www.bphc.org/bphc/pdfs/aids_provider-manual.pdf on October 4, 2007.

9. U.S. Department of Justice. [Online]. BJS Human Subjects/Confidentiality Requirements. Bureau of Justice Statistics. Retrieved from http://www.ojp.usdoj.gov/bjs/hscr.htm on October 23, 2007.

10. Steinberg, J., Lyon, D. and Vaiana, M. (1992). Urban America: Policy Choices For Los Angeles and the Nation. Rand Corporation. Los Angeles; pp 1-17.

11. Health Resources Service Administration. (2000). Ryan White Act 2000 Ammendment: PL 106-345. HIV/AIDS Bureau.

12. Health Resources Service Administration. (2000). Ryan White Care Act 2000 Compilaltion (2000 Amendments with 1996 and 1990 Text). HIV/AIDS Bureau.


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