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106th Congress 1 f Report 

2d Session HOUSE OF REPRESENTATIVES 106 _788 



RYAN WHITE CARE ACT AMENDMENTS OF 2000 



July 25, 2000.— Committed to the Committee of the Whole House on the State of 
the Union and ordered to be printed 



Mr. Bliley, from the Committee on Commerce, 
submitted the following 

REPORT 

together with 
ADDITIONAL VIEWS 

[To accompany H.R. 4807] 
[Including cost estimate of the Congressional Budget Office] 

The Committee on Commerce, to whom was referred the bill 
(H.R. 4807) to amend the Public Health Service Act to revise and 
extend programs established under the Ryan White Comprehensive 
AIDS Resources Emergency Act of 1990, and for other purposes, 
having considered the same, report favorably thereon with an 
amendment and recommend that the bill as amended do pass. 

CONTENTS 

Page 

Amendment 2 

Purpose and Summary 22 

Background and Need for Legislation 22 

Hearings 45 

Committee Consideration 45 

Committee Votes 45 

Committee Oversight Findings 46 

Committee on Government Reform Oversight Findings 46 

New Budget Authority, Entitlement Authority, and Tax Expenditures 46 

Committee Cost Estimate 46 

Congressional Budget Office Estimate 46 

Federal Mandates Statement 54 

Advisory Committee Statement 54 

Constitutional Authority Statement 54 

Applicability to Legislative Branch 54 



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Section-by-Section Analysis of the Legislation 54 

Changes in Existing Law Made by the Bill, as Reported 68 

Additional Views 114 

Amendment 
The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the "Ryan White CARE Act Amendments of 2000". 

SEC. 2. TABLE OF CONTENTS. 

The table of contents for this Act is as follows: 

TITLE I — EMERGENCY RELIEF FOR AREAS WITH SUBSTANTIAL NEED FOR SERVICES 
Subtitle A— HIV Health Services Planning Councils 

Sec. 101. Membership of councils. 
Sec. 102. Duties of councils. 

Sec. 103. Open meetings; other additional provisions. 



Sec. 111. Formula grants. 
Sec. 112. Supplemental grants. 



Subtitle B— Type and Distribution of Grants 



Subtitle C— Other Provisions 



Sec. 121. Use of amounts. 
Sec. 122. Application. 

Sec. 123. Review of administrative costs and compensation. 

TITLE II -CARE GRANT PROGRAM 
Subtitle A— General Grant Provisions 

Sec. 201. Priority for women, infants, and children. 

Sec. 202. Use of grants. 

Sec. 203. Grants to establish HIV care consortia. 

Sec. 204. Provision of treatments. 

Sec. 205. State application. 

Sec. 206. Distribution of funds. 

Sec. 207. Supplemental grants for certain States. 

Subtitle B— Provisions Concerning Pregnancy and Perinatal Transmission of HIV 

Sec. 211. Repeals. 
Sec. 212. Grants. 

Sec. 213. Study by Institute of Medicine. 

Subtitle C— Certain Partner Notification Programs 
Sec. 221. Grants for compliant partner notification programs. 

TITLE III— EARLY INTERVENTION SERVICES 
Subtitle A— Formula Grants for States 

Sec. 301. Repeal of program. 

Subtitle B— Categorical Grants 

Sec. 311. Preferences in making grants. 
Sec. 312. Planning and development grants. 
Sec. 313. Authorization of appropriations. 

Subtitle C— General Provisions 

Sec. 321. Provision of certain counseling services. 
Sec. 322. Additional required agreements. 

TITLE IV- OTHER PROGRAMS AND ACTP/ITIES 

Subtitle A— Certain Programs for Research, Demonstrations, or Training 

Sec. 401. Grants for coordinated services and access to research for women, infants, children, and youth. 
Sec. 402. AIDS education and training centert,. 

Subtitle B— General Provisions in Title XXVI 

Sec. 411. Evaluations and reports. 

Sec. 412. Data collection through Centers for Disease Control and Prevention. 

Sec. 413. Coordination. 

Sec. 414. Plan regarding release of prisoners with HIV disease. 

Sec. 415. Audits. 

Sec. 416. Administrative simplification. 

Sec. 417. Authorization of appropriations for parts A and B. 



TITLE V- GENERAL PROVISIONS 



Sec. 501. Studies by Institute of Medicine. 
Sec. 502. Development of rapid HIV test. 



3 



TITLE VI -EFFECTIVE DATE 

Sec. 601. Effective date. 

TITLE I — EMERGENCY RELIEF FOR AREAS 
WITH SUBSTANTIAL NEED FOR SERVICES 

Subtitle A-HIV Health Services Planning 
Councils 

SEC. 101. MEMBERSHIP OF COUNCILS. 

(a) In General. -Section 2602(b) of the Public Health Service Act (42 U.S.C. 
300ff-12(b)) is amended - 

(1) in paragraph (1), by striking "demographics of the epidemic in the eligible 
area involved," and inserting "demographics of the population of individuals 
with HIV disease in the eligible area involved,"; and 

(2) in paragraph (2)— 

(A) in subparagraph (G), by striking "or AIDS"; 

(B) in subparagraph (K), by striking "and" at the end; 

(C) in subparagraph (L), by striking the period and inserting the fol- 
lowing: ", including but not limited to providers of HIV prevention services; 
and"; and 

(D) by adding at the end the following subparagraph: 

"(M) representatives of individuals who formerly were Federal, State, or 
local prisoners, were released from the custody of the penal system during 
the preceding three years, and had HIV disease as of the date on which the 
individuals were so released.". 

(b) Conflicts of Interests.— Section 2602(b)(5) of the Public Health Service Act 
(42 U.S.C. 300ff-12(bX5)) is amended by adding at the end the following subpara- 
graph: 

"(C) Composition of council.— The following applies regarding the 
membership of a planning council under paragraph (1): 

"(i) Not less than 33 percent of the council shall be individuals who 
are receiving HTV-related services pursuant to a grant under section 
2601(a), are not officers, employees, or consultants to any entity that 
receives amounts from such a grant, and do not represent any such en- 
tity, and reflect the demographics of the population of individuals with 
HIV disease as determined under paragraph (4)(A). For purposes of the 
preceding sentence, an individual shall be considered to be receiving 
such services if the individual is a parent of, or a caregiver for, a minor 
child who is receiving such services. 

"(ii) With respect to membership on the planning council, clause (i) 
may not be construed as having any effect on entities that receive 
funds from grants under any of parts B through F but do not receive 
funds from grants under section 2601(a), on officers or employees of 
such entities, or on individuals who represent such entities.". 

SEC. 102. DUTIES OF COUNCILS. 

(a) In General. -Section 2602(b)(4) of the Public Health Service Act (42 U.S.C. 
300ff-12(b)(4)) is amended- 

(1) by redesignating subparagraphs (A) through (E) as subparagraphs (C) 
through (G), respectively; 

(2) by inserting before subparagraph (C) (as so redesignated) the following 
subparagraphs: 

"(A) determine the size and demographics of the population of individuals 
with HIV disease; 

"(B) determine the needs of such population, with particular attention 
to— 

"(i) individuals with HIV disease who are not receiving HlV-related 
services; and 

"(ii) disparities in access and services among affected subpopulations 
and historically underserved communities;"; 

(3) in subparagraph (C) (as so redesignated), by striking clauses (i) through 
(iv) and inserting the following: 

"(i) size and demographics of the population of individuals with HIV 
disease (as determined under subparagraph (A)) and the needs of such 
population (as determined under subparagraph (B)); 



4 

"(ii) demonstrated (or probable) cost effectiveness and outcome effec- 
tiveness of proposed strategies and interventions, to the extent that 
data are reasonably available; 

"(iii) priorities of the communities with HIV disease for whom the 
services are intended; 

"(iv) availability of other governmental and nongovernmental re- 
sources to provide HIV-related services to individuals and families with 
HIV disease, including the State plan under title XIX of the Social Se- 
curity Act (relating to the Medicaid program) and the program under 
title XXI of such Act (relating to the program for State children's health 
insurance); and 

"(v) capacity development needs resulting from disparities in the 
availability of HIV-related services in historically underserved commu- 
nities;"; 

(4) in subparagraph (D) (as so redesignated), by amending the subparagraph 
to read as follows: 

"(D) develop a comprehensive plan for the organization and delivery of 
health and support services described in section 2604 that— 

"(i) includes a strategy for identifying individuals with HIV disease 
who are not receiving such services and for informing the individuals 
of and enabling the individuals to utilize the services, giving particular 
attention to eliminating disparities in access and services among af- 
fected subpopulations and historically underserved communities, and 
including discrete goals, a timetable, and an appropriate allocation of 
funds; 

"(ii) includes a strategy to coordinate the provision of such services 
with programs for HIV prevention and for the prevention and treat- 
ment of substance abuse, including programs that provide comprehen- 
sive treatment services for such abuse; and 

"(iii) is compatible with any State or local plan for the provision of 
services to individuals with HIV disease;"; 

(5) in subparagraph (F) (as so redesignated), by striking "and" at the end; 

(6) in subparagraph (G) (as so redesignated)— 

(A) by striking "public meetings," and inserting "public meetings (in ac- 
cordance with paragraph (7)),"; and 

(B) by striking the period and inserting "; and"; and 

(7) by adding at the end the following subparagraph: 

"(H) coordinate with Federal grantees that provide HIV-related services 
within the eligible area.". 

(b) Process for Establishing Allocation Priorities.— Section 2602 of the Pub- 
lic Health Service Act (42 U.S.C. 300ff-12) is amended by adding at the end the 
following subsection: 

"(d) Process for Establishing Allocation Priorities.— Promptly after the date 
of the submission of the report required in section 501(b) of the Ryan White CARE 
Act Amendments of 2000 (relating to the relationship between epidemiological 
measures and health care for certain individuals with HIV disease), the Secretary, 
in consultation with entities that receive amounts from grants under section 2601(a) 
or 2611, shall develop epidemiologic measures— 

"(1) for establishing the number of individuals living with HTV disease who 
are not receiving HIV-related health services; and 
"(2) for carrying out the duties under subsection (b)(4) and section 2617(b).". 

(c) Training. -Section 2602 of the Public Health Service Act (42 U.S.C. 300ff-12), 
as amended by subsection (b) of this section, is amended by adding at the end the 
following subsection: 

"(e) Training Guidance and Materials.— The Secretary shall provide to each 
chief elected official receiving a grant under 2601(a) guidelines and materials for 
training members of the planning council under paragraph (1) regarding the duties 
of the council.". 

SEC 103. OPEN MEETINGS; OTHER ADDITIONAL PROVISIONS. 

Section 2602(b) of the Public Health Service Act (42 U.S.C. 300ff-12(b)) is 
amended— 

(1) in paragraph (3), by striking subparagraph (C); and 

(2) by adding at the end the following paragraph: 

"(7) Public deliberations.— With respect to a planning council under para- 
graph (1), the following applies: 

"(A) The council may not be chaired solely by an employee of the grantee 
under section 2601(a). 
"(B) In accordance with criteria established by the Secretary: 



"(i) The meetings of the council shall be open to the public and shall 
be held only after adequate notice to the public. 

"(ii) The records, reports, transcripts, minutes, agenda, or other docu- 
ments which were made available to or prepared for or by the council 
shall be available for public inspection and copying at a single location. 

"(iii) Detailed minutes of each meeting of the council shall be kept. 
The accuracy of all minutes shall be certified to by the chair of the 
council. 

"(iv) This subparagraph does not apply to any disclosure of informa- 
tion of a personal nature that would constitute a clearly unwarranted 
invasion of personal privacy, including any disclosure of medical infor- 
mation or personnel matters.". 

Subtitle B— Type and Distribution of Grants 

SEC. 111. FORMULA GRANTS. 

(a) Expedited Distribution.— Section 2603(a)(2) of the Public Health Service Act 
(42 U.S.C. 300ff-13(a)(2)) is amended in the first sentence by striking "for each of 
the fiscal years 1996 through 2000" and inserting "for a fiscal year". 

(b) Amount of Grant; Estimate of Living Cases.— 

(1) In general. -Section 2603(a)(3)) of the Public Health Service Act (42 
U.S.C. 300fi°-13(a)(3)) is amended- 

(A) in subparagraph (C)(i), by inserting before the semicolon the fol- 
lowing: ", except that (subject to subparagraph (D)), for grants made pursu- 
ant to this paragraph for fiscal year 2005 and subsequent fiscal years, the 
cases counted for each 12-month period beginning on or after July 1, 2004, 
shall be cases of HIV disease (as reported to and confirmed by such Direc- 
tor) rather than cases of acquired immune deficiency syndrome"; and 

(B) in subparagraph (C), in the matter after and below clause (ii)(X)— 

(i) in the first sentence, by inserting before the period the following: 
", and shall be reported to the congressional committees of jurisdiction '; 
and 

(ii) by adding at the end the following sentence: "Updates shall as ap- 
plicable take into account the counting of cases of HIV disease pursu- 
ant to clause (i)." 

(2) Determination of secretary regarding data on hiv cases.— Section 
2603(a)(3)) of the Public Health Service Act (42 U.S.C. 300ff-13(a)(3)) is 
amended — 

(A) by redesignating subparagraph (D) as subparagraph (E); and 

(B) by inserting after subparagraph (C) the following subparagraph: 
"(D) Determination of secretary regarding data on hiv cases.— 

"(i) In general.— Not later than July 1, 2004, the Secretary shall de- 
termine whether there is data on cases of HIV disease from all eligible 
areas (reported to and confirmed by the Director of the Centers for Dis- 
ease Control and Prevention) sufficiently accurate and reliable for use 
for purposes of subparagraph (C)(i). In making such a determination, 
the Secretary shall take into consideration the findings of the study 
under section 501(b) of the Ryan White CARE Act Amendments of 2000 
(relating to the relationship between epidemiological measures and 
health care for certain individuals with HIV disease), the fiscai impact 
of the use of such data, the impact of the use of such data on the orga- 
nization and delivery of HIV-related services in eligible areas, and the 
fiscal impact of not using such data. 

"(ii) Effect of adverse determination.— If under clause (i) the Sec- 
retary determines that data on cases of HIV disease is not sufficiently 
accurate and reliable for use for purposes of subparagraph (C)(i), then 
notwithstanding such subparagraph, for any fiscal year prior to fiscal 
year 2007 the references in such subparagraph to cases of HIV disease 
do not have any legal effect. 

"(iii) Grants and technical assistance regarding counting of 
hiv cases.— Of the amounts appropriated under section 2675 for a fis- 
cal year, the Secretary shall reserve amounts to make grants and pro- 
vide technical assistance to States and eligible areas with respect to ob- 
taining data on cases of HIV disease to ensure that data on such cases 
is available from all States and eligible areas as soon as is practicable 
but not later than the beginning of fiscal year 2007.". 

(c) Increases in Grant.— Section 2603(a)(4)) of the Public Health Service Act (42 
U.S.C. 300ff-13(a)(4)) is amended to read as follows: 



6 



"(4) Increases in grant.— 

"(A) In general.— For each fiscal year in a protection period for an eligi- 
ble area, the Secretary shall increase the amount of the grant made pursu- 
ant to paragraph (2) for the area to ensure that— 

"(i) for the first fiscal year in the protection period, the grant is not 
less than 98 percent of the amount of the grant made for the eligible 
area pursuant to such paragraph for the base year for the protection 
period; 

"(ii) for any second fiscal year in such period, the grant is not less 
than 95.7 percent of the amount of such base year grant; 

"(iii) for any third fiscal year in such period, the grant is not less 
than 91.1 percent of the amount of the base year grant; 

"(iv) for any fourth fiscal year in such period, the grant is not less 
than 84.2 percent of the amount of the base year grant; and 

"(v) for any fifth or subsequent fiscal year in such period, the grant 
is not less than 75 percent of the amount of the base year grant. 
"(B) Base year; protection period.— With respect to grants made pur- 
suant to paragraph (2) for an eligible area: 

"(i) The base year for a protection period is the fiscal year preceding 
the trigger grant-reduction year. 

"(ii) The first trigger grant-reduction year is the first fiscal year (after 
fiscal year 2000) for which the grant for the area is less than the grant 
for the area for the preceding fiscal year. 

"(iii) A protection period begins with the trigger grant-reduction year 
and continues until the beginning of the first fiscal year for which the 
amount of the grant for the area equals or exceeds the amount of the 
grant for the base year for the period. 

"(iv) Any subsequent trigger grant-reduction year is the first fiscal 
year, after the end of the preceding protection period, for which the 
amount of the grant is less than the amount of the grant for the pre- 
ceding fiscal year.". 

SEC. 112. SUPPLEMENTAL GRANTS. 

(a) In General. -Section 2603(b)(2) of the Public Health Service Act (42 U.S.C. 
300ff-13(b)(2)) is amended- 

(1) in the heading for the paragraph, by striking "Definition" and inserting 
"Amount of grant"; 

(2) by redesignating subparagraphs (A) through (C) as subparagraphs (B) 
through (D), respectively; 

(3) by inserting before subparagraph (B) (as so redesignated) the following 
subparagraph: 

"(A) In general.— The amount of each grant made for purposes of this 
subsection shall be determined by the Secretary based on a weighting of 
factors under paragraph (1), with severe need under subparagraph (B) of 
such paragraph counting one-third."; 

(4) in subparagraph (B) (as so redesignated)— 

(A) in clause (ii), by striking "and" at the end; 

(B) in clause (iii), by striking the period and inserting a semicolon; and 

(C) by adding at the end the following clauses: 
"(iv) the current prevalence of HIV disease; 

"(v) an increasing need for HlV-related services, including relative 
rates of increase in the number of cases of HIV disease; and 

"(vi) unmet need for such services, as determined under section 
2602(b)(4)."; 

(5) in subparagraph (C) (as so redesignated)— 

(A) by striking "subparagraph (A)" each place such term appears and in- 
serting "subparagraph (B)'"; 

(B) in the second sentence, by striking "2 years after the date of enact- 
ment of this paragraph" and inserting "18 months after the date of the en- 
actment of the Ryan White CARE Act Amendments of 2000"; and 

(C) by inserting after the second sentence the following sentence: "Such 
a mechanism shall be modified to reflect the findings of the study under 
section 501(b) of the Ryan White CARE Act Amendments of 2000 (relating 
to the relationship between epidemiological measures and health care for 
certain individuals with HTV disease)."; and 

(6) in subparagraph (D) (as so redesignated), by striking "subparagraph (B)" 
and inserting "subparagraph (C)"\ 



(b) Requirements for Application.— Section 2603(b)(lXE) of the Public Health 
Service Act (42 U.S.C. 300ff-13(b)(l)(E)) is amended by inserting "youth," after 
"children,". 

(c) Conforming Amendment.— Section 2603(b) of the Public Health Service Act 
(42 U.S.C. 300ff-13(b)) is amended- 

(1) by striking paragraph (4); and 

(2) by redesignating paragraph (5) as paragraph (4). 

Subtitle C— Other Provisions 

SEC. 121. USE OF AMOUNTS. 

(a) Primary Purposes.— Section 2604(b)(1) of the Public Health Service Act (42 
U.S.C. 300ff-14(b)(D) is amended- 

(1) in the matter preceding subparagraph (A), by striking "HIV-related— " and 
inserting "HIV-related services, as follows:"; 

(2) in subparagraph (A)— 

(A) by striking "outpatient" and all that follows through "substance abuse 
treatment and" and inserting the following: "Outpatient and ambulatory 
health services, including substance abuse treatment,"; and 

(B) by striking "; and" and inserting a period; 

(3) in subparagraph (B), by striking "(B) inpatient case management" and in- 
serting "(C) Inpatient case management"; 

(4) by inserting after subparagraph (A) the following subparagraph: 

"(B) Outpatient and ambulatory support services (including case manage- 
ment), to the extent that such services facilitate, support, or sustain the de- 
livery, or benefits of health services for individuals and families with HIV 
disease."; and 

(5) by adding at the end the following: 

"(D) Outreach activities that are intended to identify individuals with 
HIV disease who are not receiving HIV-related services, and that are— 

"(i) necessary to implement the strategy under section 2602(b)(4)(D), 
including activities facilitating the access of such individuals to HIV- 
related primary care services at entities described in paragraph (3); 

"(ii) conducted in a manner consistent with the requirements under 
sections 2605(a)(3) and 2651(b)(2); and 

"(iii) supplement, and do not supplant, such activities that are car- 
ried out with amounts appropriated under section 317.". 

(b) Additional Purposes. -Section 2604(b) (42 U.S.C. 300ff-14(b)) of the Public 
Health Service Act is amended— 

(1) by redesignating paragraph (3) as paragraph (4); 

(2) by inserting after paragraph (2) the following: 
"(3) Early intervention services.— 

"(A) In GENERAL.— The purposes for which a grant under section 2601 
may be used include providing to individuals with HIV disease early inter- 
vention services described in section 2651(b)(2) (including referrals under 
subparagraph (C) of such section), subject to subparagraph (B). The entities 
through which such services may be provided under the grant include pub- 
lic health departments, emergency rooms, substance abuse and mental 
health treatment programs, detoxification centers, detention facilities, clin- 
ics regarding sexually transmitted diseases, homeless shelters, HIV disease 
counseling and testing sites, health care points of entry specified by States 
or eligible areas, federally qualified health centers, and entities described 
in section 2652(a). 

"(B) Conditions.— With respect to an entity that proposes to provide 
early intervention services under subparagraph (A), such subparagraph ap- 
plies only if the entity demonstrates to the satisfaction of the chief elected 
official for the eligible area involved that— 

"(i) Federal, State, or local funds are otherwise inadequate for the 
early intervention services the entity proposes to provide; and 

"(ii) the entity will expend funds pursuant to such subparagraph to 
supplement and not supplant other funds available to the entity for the 
provision of early intervention services for the fiscal year involved."; 
and 

(3) in paragraph (4) (as so redesignated), by inserting "youth," after "chil- 
dren," each place such term appears; 

(c) Quality Management. -Section 2604 of the Public Health Service Act (42 
U.S.C. 300ff-14) is amended- 



8 

(1) by redesignating subsections (c) through (f) as subsections (d) through (g), 
respectively; and 

(2) by inserting after subsection (b) the following: 
"(c) Quality Management. — 

"(1) Requirement.— The chief elected official of an eligible area that receives 
a grant under this part shall provide for the establishment of a quality manage- 
ment program to assess the extent to which HIV health services provided to pa- 
tients under the grant are consistent with the most recent Public Health Serv- 
ice guidelines for the treatment of HIV disease and related opportunistic infec- 
tion, and as applicable, to develop strategies for ensuring that such services are 
consistent with the guidelines. 

"(2) Use of funds.— From amounts received under a grant awarded under 
this part for a fiscal year, the chief elected official of an eligible area may (in 
addition to amounts to which subsection (f)(1) applies) use for activities associ- 
ated with the quality management program required in paragraph (1) not more 
than the lesser of— 

"(A) 5 percent of amounts received under the grant; or 
"(B) $3,000,000.". 

SEC. 122. APPLICATION. 

Section 2605(a) of the Public Health Service Act (42 U.S.C. 300ff-15(a)) is 
amended— 

(1) by redesignating paragraphs (3) through (6) as paragraphs (4) through (7), 
respectively; and 

(2) by inserting after paragraph (2) the following paragraph: 

"(3) that entities within the eligible area that receive funds under a grant 
under section 2601(a) will maintain relationships with appropriate entities in 
the area, including entities described in section 2604(b)(3);' . 

SEC. 123. REVIEW OF ADMINISTRATIVE COSTS AND COMPENSATION. 

Each chief elected official of an eligible area (as defined in section 2607 of the 
Public Health Service Act) shall ensure that, not later than one year after the date 
of the enactment of this Act, the planning council for the eligible area— 

(1) conducts a review of the existing, available data on the extent to which 
entities in the area that receive amounts from a grant under section 2601(a) 
of the Public Health Service Act have from their overall budget expended 
amounts for administrative costs (including financial compensation and bene- 
fits), expressed as a proportion and indicating the growth in such expenditures, 
including a statement of the average amount expended for such costs per client 
served and the average amount expended for such costs per client served in pro- 
viding HIV-related services; and 

(2) makes a determination of whether the financial compensation of any offi- 
cers or employees of such entities exceeds that of the chief elected official of the 
eligible area. 

TITLE II-CARE GRANT PROGRAM 
Subtitle A— General Grant Provisions 



SEC. 201. PRIORITY FOR WOMEN, INFANTS, AND CHILDREN. 

Section 2611(b) of the Public Health Service Act (42 U.S.C. 300ff-21(b)) is amend- 
ed by inserting "youth," after "children," each place such term appears. 

SEC. 202. USE OF GRANTS. 

Section 2612 of the Public Health Service Act (42 U.S.C. 300ff-22) is amended- 

(1) by striking "A State may use" and inserting "(a) In General.— A State 
may use"; and 

(2) by adding at the end the following subsections: 

"(b) Support Services; Outreach.— The purposes for which a grant under this 
part may be used include delivering or enhancing the following: 

"(1) Support services under section 2611(a) (including case management) to 
the extent that such services facilitate, support, or sustain the delivery, or bene- 
fits of health services for individuals and families with HIV disease. 

"(2) Outreach activities that are intended to identify individuals with HIV dis- 
ease who are not receiving HIV-related services, and that are— 

"(A) necessary to implement the strategy under section 2617(b)(4)(B); 
"(B) conducted in a manner consistent with the requirement under sec- 
tion 2617(b)(6)(G); and 



9 



"(C) supplement, and do not supplant, such activities that are carried out 
with amounts appropriated under section 317. 
"(c) Early Intervention Services.— 

"(1) Lx general.— The purposes for which a grant under this part may be 
used include providing to individuals with HIV disease early intervention serv- 
ices described in section 2651(bX2) (including referrals under subparagraph (C) 
of such section ), subject to paragraph (2). The entities through which such serv- 
ices may be provided under the grant include public health departments, emer- 
gency rooms, substance abuse and mental health treatment programs, detoxi- 
fication centers, detention facilities, clinics regarding sexually transmitted dis- 
eases, homeless shelters. HIV disease counseling and testing sites, health care 
points of entry specified by States or eligible areas, federally qualified health 
centers, and entities described in section 2652(a). 

"(2) Conditions.— With respect to an entity that proposes to provide early 
intervention services under paragraph (1), such paragraph applies only if the 
entity demonstrates to the satisfaction of the State involved that— 

"(A) Federal, State, or local funds are otherwise inadequate for the early 
intervention services the entity proposes to provide; and 

"(B) the entity will expend funds pursuant to such paragraph to supple- 
ment and not supplant other funds available to the entity for the provision 
of early intervention services for the fiscal year involved. 
"(d) Quality^Lanagenient.— 

"(1) Requirement.— Each State that receives a grant under this part shall 
provide for the establishment of a quality management program to assess the 
extent to which HTV health services provided to patients under the grant are 
consistent with the most recent Public Health Service guidelines for the treat- 
ment of HTV disease and related opportunistic infection, and as applicable, to 
develop strategies for ensuring that such services are consistent with the guide- 
lines. 

"(2) Use of funds.— From amounts received under a grant awarded under 
this part for a fiscal year, the State may (in addition to amounts to which sec- 
tion 2618(cX5) applies) use for activities associated with the quality manage- 
ment program required in paragraph (1) not more than the lesser of— 

"(A) 5 percent of amounts received under the grant; or 

"(B) $3,000,000.". 

SEC. 203. GRANTS TO ESTABLISH HTV CARE CONSORTIA 

Section 2613 of the Public Health Service Act (42 U.S.C. 300ff-23) is amended— 

(1) in subsection (bXD— 

(A) in subparagraph (A), by inserting before the semicolon the following: 
", particularly those experiencing disparities in access and services and 
those who reside in historically underserved communities"; and 

(B) in subparagraph (B), by inserting after '1by such consortium" the fol- 
lowing: "is consistent with the comprehensive plan under 2617(bX4) and"; 

(2) in subsection (cXl)— 

(A) in subparagraph CD), by striking "and" after the semicolon at the end; 

(B) in subparagraph (E), by striking the period and inserting "; and"; 

(C) by adding at the end the following subparagraph: 

"(F) demonstrates that adequate planning occurred to address disparities 
in access and services and historically underserved communities."; and 

(3) in subsection (cX2)— 

(A) in subparagraph (B >, by striking "and" after the semicolon; 

(B) in subparagraph (C), by striking the period and inserting "; and"; and 
id by inserting after subparagraph (C) the following subparagraph; 

"(D) entities described in section 2602(b)(2).". 

SEC. 204. PROVISION OF ITiEATMENTS, 

Section 2616 of the Public Health Service Act (42 U.S.C. 300ff-26) is amended by 
adding at the end the following subsection: 

"(e) Use of Health Insurance and Plans.— In carrying out subsection (a), a 
State may expend a grant under this part to provide the therapeutics described in 
such subsection by paying on behalf of individuals with HTV disease the costs of 
purchasing or maintaining health insurance or plans whose coverage includes a full 
range of such therapeutics and appropriate primary care services.". 

SEC. 205. STATE APPLICATION. 

(a) Determination of Size and Needs of Population; Comprehensive Plan.— 
Section 2617i b> of the Public Health Service Act (42 U.S.C. 300ff-27(b)) is 
amended— 



10 

(1) by redesignating paragraphs (2) through (4) as paragraphs (4) through (6), 
respectively; 

(2) by inserting after paragraph (1) the following paragraphs: 
"(2) a determination of the size and demographics of the population of individ- 
uals with HIV disease in the State; 

"(3) a determination of the needs of such population, with particular attention 
to— 

"(A) individuals with HIV disease who are not receiving HIV-related serv- 
ices; and 

"(B) disparities in access and services among affected subpopulations and 
historically underserved communities;"; and 

(3) in paragraph (4) (as so redesignated)— 

(A) by striking "comprehensive plan for the organization" and inserting 
"comprehensive plan that describes the organization"; 

(B) by striking ", including—" and inserting ", and that—"; 

(C) by redesignating subparagraphs (A) through (C) as subparagraphs (D) 
through (F), respectively; 

(D) by inserting before subparagraph (C) the following subparagraphs: 
"(A) establishes priorities for the allocation of funds within the State 

based on— 

"(i) size and demographics of the population of individuals with HIV 
disease (as determined under paragraph (2)) and the needs of such pop- 
ulation (as determined under paragraph (3)); 

"(ii) availability of other governmental and nongovernmental re- 
sources to provide HIV-related services to individuals and families with 
HIV disease; 

"(iii) capacity development needs resulting from disparities in the 
availability of HIV-related services in historically underserved commu- 
nities and rural communities; and 

"(iv) the efficiency of the administrative mechanism of the State for 
rapidly allocating funds to the areas of greatest need within the State; 
"(B) includes a strategy for identifying individuals with HIV disease who 
are not receiving such services and for informing the individuals of and en- 
abling the individuals to utilize the services, giving particular attention to 
eliminating disparities in access and services among affected subpopula- 
tions and historically underserved communities, and including discrete 
goals, a timetable, and an appropriate allocation of funds; 

"(C) includes a strategy to coordinate the provision of such services with 
programs for HTV prevention and for the prevention and treatment of sub- 
stance abuse, including programs that provide comprehensive treatment 
services for such abuse;"; 

(E) in subparagraph (D) (as redesignated by subparagraph (C) of this 
paragraph), by inserting "describes" before "the services and activities"; 

(F) in subparagraph (E) (as so redesignated), by inserting "provides" be- 
fore "a description"; and 

(G) in subparagraph (F) (as so redesignated), by inserting "provides" be- 
fore "a description". 

(b) Public Participation. -Section 2617(b) of the Public Health Service Act, as 
amended by subsection (a) of this section, is amended— 

(1) in paragraph (5), by striking "HIV and inserting "HIV disease"; and 

(2) in paragraph (6), by amending subparagraph (A) to read as follows: 

"(A) the public health agency that is administering the grant for the State 
engages in a public advisory planning process, including public hearings, 
that includes the participants under paragraph (5), and entities described 
in section 2602(b)(2), in developing the comprehensive plan under para- 
graph (4) and commenting on the implementation of such plan;". 

(c) Health Care Relationships. -Section 2617(b) of the Public Health Service 
Act, as amended by subsection (a) of this section, is amended in paragraph (6)— 

(1) in subparagraph (E), by striking "and" at the end; 

(2) in subparagraph (F), by striking the period and inserting "; and"; and 

(3) by adding at the end the following subparagraph: 

"(G) entities within areas in which activities under the grant are carried 
out will maintain relationships with appropriate entities in the area, in- 
cluding entities described in section 2612(c);". 

SEC. 206. DISTRIBUTION OF FUNDS. 

(a) Minimum Allotment.- Section 2618(b)(l)(A)(i) of the Public Health Service 
Act (42 U.S.C. 300ff-28(b)(l)(A)(i)) is amended- 

(1) in subclause (I), by striking "$100,000" and inserting "$200,000"; and 



11 



(2) in subclause (II), by striking "$250,000" and inserting "$500,000". 

(b) Amount of Grant; Estimate of Living Cases.— Section 2618(b)(2) of the 
Public Health Service Act (42 U.S.C. 300fT-28(bX2)) is amended- 

(1) in subparagraph (D)(i), by inserting before the semicolon the following: ", 
except that (subject to subparagraph (E)), for grants made pursuant to this 
paragraph for fiscal year 2005 and subsequent fiscal years, the cases counted 
for each 12-month period beginning on or after July 1, 2004, shall be cases of 
HIV disease (as reported to and confirmed by such Director) rather than cases 
of acquired immune deficiency syndrome"; 

(2) by redesignating subparagraphs (E) through (H) as subparagraphs (F) 
through (I), respectively; and 

(3) by inserting after subparagraph (D) the following subparagraph: 

"(E) Determination of secretary regarding data on htv cases.— If 
under 2603(aX3)(DXi) the Secretary determines that data on cases of HTV 
disease is not sufficiently accurate and reliable, then notwithstanding sub- 
paragraph (D) of this paragraph, for any fiscal year prior to fiscal year 2007 
the references in such subparagraph to cases of HIV disease do not have 
any legal effect.". 

(c) Increases in Formula Amount.— Section 2618(b) of the Public Health Service 
Act (42 U.S.C. 300ff-28(b)) is amended- 

(1) in paragraph (lXAXii), by inserting before the semicolon the following: 
"and then, as applicable, increased under paragraph (2)(H)"; and 

(2) in paragraph (2)— 

(A) in subparagraph (A)(i), by striking "subparagraph (H)" and inserting 
"subparagraphs (H) and (I)"; and 

(B) in subparagraph (H) (as redesignated by subsection (b)(2) of this sec- 
tion), by amending the subparagraph to read as follows: 

"(H) Limitation.— 

"(i) In general. — The Secretary shall ensure that the amount of a 
grant awarded to a State or territory under section 2611 for a fiscal 
year is not less than— 

"(I) with respect to fiscal year 2001, 99 percent; 

"(II) with respect to fiscal year 2002, 98 percent; 

"(III) with respect to fiscal year 2003, 97 percent; 

"(IV) with respect to fiscal year 2004, 96 percent; and 

"(V) with respect to fiscal year 2005, 95 percent; 
of the amount such State or territory received for fiscal year 2000 
under such section. In administering this subparagraph, the Secretary 
shall, with respect to States or territories that will under such section 
receive grants in amounts that exceed the amounts that such States re- 
ceived under such section for fiscal year 2000, proportionally reduce 
such amounts to ensure compliance with this subparagraph. In making 
such reductions, the Secretary shall ensure that no such State receives 
less than that State received for fiscal year 2000. 

"(ii) Ratable reduction.— If the amount appropriated under section 
2677 for a fiscal year and available for grants under section 2611 is less 
than the amount appropriated and available under such section for fis- 
cal year 2000, the limitation contained in clause (i) shall be reduced by 
a percentage equal to the percentage of the reduction in such amounts 
appropriated and available.". 

(d) Territories. — Section 2618(b)(1)(B) of the Public Health Service Act (42 
U.S.C. 300ff-28(b)(lXB)) is amended by inserting "the greater of $50,000 or" after 
"shall be". 

(e) Separate Treatment Drug Grants. — Section 2618(b)(2) of the Public Health 
Service Act, as amended by subsection (b)(3) of this section, is amended in subpara- 
graph (I)— 

(1) by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively; 

(2) by striking "I 1 1 APPROPRIATIONS" and all that follows through "With re- 
spect to" and inserting the following: 

"(I) Approprlations for treatment drug program.— 
"(i ) Formula grants.— With respect to"; 

(3) in subclause (I) of clause (i) (as designated by paragraphs (1) and (2)), by 
striking "100 percent" and inserting "98 percent"; and 

(4) by adding at the end the following clause: 

'•(ii) Supplemental treatment drug grants.— 

"(I) In general.— With respect to the fiscal year involved, if 
under section 2677 an appropriations Act provides an amount ex- 
clusively for carrying out section 2616, and such amount is not less 
than the amount so provided for the preceding fiscal year, the Sec- 



12 

retary shall reserve 2 percent of such amount for making grants 
to States whose population of individuals with HIV disease has, as 
determined by the Secretary, a need for quantities of therapeutics 
described in section 2616(a) greater than the quantities available 
pursuant to clause (i). Such a grant is available for purposes of ob- 
taining such therapeutics. The Secretary shall carry out this clause 
as a program of discretionary grants, and not as a program of for- 
mula grants. 

"(II) Distribution of grants.— The Secretary shall disburse all 
amounts under grants under subclause (I) for a fiscal year not later 
than 240 days after the date on which the amount referred to in 
such subclause with respect to section 2616 becomes available. 

"(Ill) Requirement of matching funds.— A condition for receiv- 
ing a grant under subclause (I) is that the State agree to make 
available (directly or through donations from public or private enti- 
ties) non-Federal contributions toward the costs of obtaining the 
therapeutics involved in an amount that is not less than 25 percent 
of such costs (determined in the same manner as under 
2617(d)(2)(A)).". 

(f) Technical Amendment.— Section 2618(b)(3)(B) of the Public Health Service 
Act (42 U.S.C. 300ff-28(b)(3)(B)) is amended by striking "and the Republic of the 
Marshall Islands" and inserting "the Republic of the Marshall Islands, the Fed- 
erated States of Micronesia, and the Republic of Palau, and only for purposes of 
paragraph (1) the Commonwealth of Puerto Rico". 

SEC. 207. SUPPLEMENTAL GRANTS FOR CERTAIN STATES. 

Subpart I of part B of title XXVI of the Public Health Service Act (42 U.S.C. 
300ff-ll et seq.) is amended— 

(1) by striking section 2621; and 

(2) by inserting after section 2620 the following section: 

"SEC. 2621. SUPPLEMENTAL GRANTS. 

"(a) In General.— From amounts available pursuant to subsection (d) for a fiscal 
year, the Secretary shall make grants to States that meet the conditions to receive 
grants under section 2611, and that have one or more eligible communities, for the 
purpose of providing in such communities comprehensive services of the type de- 
scribed in section 2612(a) to supplement the development and care activities, pri- 
mary care, and support services otherwise provided in such communities by the 
State under a grant under section 2611. 

"(b) Eligible Community.— For purposes of this section, the term 'eligible com- 
munity' means a geographic area that- 
'll) is not within any eligible area as defined in section 2607; and 
"(2) has a severe need for supplemental financial assistance to combat the 
HIV epidemic, according to criteria developed by the Secretary in consultation 
with the States, including evidence of underserved or rural areas or both. 
"(c) Application. —A grant under subsection (a) may be made to a State if the 
State submits to the Secretary, as part of the State application submitted under sec- 
tion 2617, such information as required to apply for funds under this section as de- 
termined by the Secretary in consultation with the States. 
"(d) Funding.— 

"(1) In general.— For the purpose of making grants under subsection (a) for 
a fiscal year, the Secretary shall reserve 50 percent of the amount specified in 
paragraph (2). 
"(2) Increases in part b funding.— 

"(A) In general.— For purposes of paragraph (1), the amount specified in 
this paragraph is the amount by which the amount appropriated under sec- 
tion 2677 for the fiscal year involved and available for carrying out part B 
is an increase over the amount so appropriated and available for the pre- 
ceding fiscal year, subject to subparagraphs (B) and (C). 

"(B) Initial allocation year. -The allocation under paragraph (1) shall 
not be made until the first fiscal year for which the amount appropriated 
under section 2677 for the fiscal year involved and available for carrying 
out part B is an increase of not less than $20,000,000 over the amount so 
appropriated and available for fiscal year 2000, subject to subparagraph 
(C). 

"(C) Exclusion regarding separate treatment drug grants.— Each 
determination under subparagraph (A) or (B) of the amount appropriated 
under section 2677 for a fiscal year and available for carrying out part B 
shall be made without regard to any amount to which section 
2618(b)(2)(I)(i) applies.". 



13 



Subtitle B— Provisions Concerning Pregnancy and 
Perinatal Transmission of HIV 

SEC. 211. REPEALS. 

Subpart II of part B of title XXVI of the Public Health Service Act (42 U.S.C. 
300ff-33 et seq.) is amended— 

(1) in section 2626, by striking each of subsections (d) through (f); and 

(2) by striking section 2627. 

SEC. 212. GRANTS. 

(a) In General. -Section 2625(c) of the Public Health Service Act (42 U.S.C. 
300ff-33) is amended— 

(1) in paragraph (1), by inserting at the end the following subparagraph: 

"(F) Making available to pregnant women with HIV disease, and to the 
infants of women with such disease, treatment services for such disease in 
accordance with applicable recommendations of the Secretary."; 

(2) by amending paragraph (2) to read as follows: 
"(2) Funding. — 

"(A) Authorization of appropriations.— For the purpose of carrying out 
this subsection, there are authorized to be appropriated $30,000,000 for 
each of the fiscal years 2001 through 2005. Amounts made available under 
section 2677 for carrying out this part are not available for carrying out 
this section unless otherwise authorized. 
"(B) Allocations for certain states.— 

"(i) In general.— Of the amounts appropriated under subparagraph 
(A) for a fiscal year in excess of $10,000,000, the Secretary shall reserve 
the applicable percentage under clause (ii) for making grants under 
paragraph (1) to States that under law (including under regulations or 
the discretion of State officials) have— 

"(I) a requirement that all newborn infants born in the State be 
tested for HTV disease; or 

"(II) a requirement that newborn infants born in the State be 
tested for HIV disease in circumstances in which the attending ob- 
stetrician for the birth does not know the HTV status of the mother 
of the infant. 

"(ii) Applicable percentage.— For purposes of clause (i), the appli- 
cable amount for a fiscal year is as follows: 
"(I) For fiscal year 2001, 25 percent. 
"(II) For fiscal year 2002, 50 percent. 
"(Ill) For fiscal year 2003, 50 percent. 
"(IV) For fiscal year 2004, 75 percent. 
"(V) For fiscal year 2005, 75 percent. 
"(C) Certain provisions.— With respect to grants under paragraph (1) 
that are made with amounts reserved under subparagraph (B) of this para- 
graph: 

"(i) Such a grant may not be made in an amount exceeding 
$4,000,000. 

"(ii) If pursuant to clause (i) or pursuant to an insufficient number 
of qualifying applications for such grants (or both), the full amount re- 
served under subparagraph (B) for a fiscal year is not obligated, the re- 
quirement under such subparagraph to reserve amounts ceases to 
apply."; and 

(3) by adding at the end the following paragraph: 

"(4) Maintenance of effort.— A condition for the receipt of a grant under 
paragraph (1) is that the State involved agree that the grant will be used to 
supplement and not supplant other funds available to the State to carry out the 
purposes of the grant.". 

(b) Special Funding Rule for Fiscal Year 2001.— 

(1) In general.— If for fiscal year 2001 the amount appropriated under para- 

fraph (2XA) of section 2625(c) of the Public Health Service Act is less than 
14,000,000- 

(A) the Secretary of Health and Human Services shall, for the purpose 
of making grants under paragraph (1) of such section, reserve from the 
amount specified in paragraph (2) of this subsection an amount equal to the 
difference between $14,000,000 and the amount appropriated under para- 
graph (2)(A) of such section for such fiscal year; 



14 

(B) the amount so reserved shall, for purposes of paragraph (2)(B)(i) of 
such section, be considered to have been appropriated under paragraph 
(2)(A) of such section; and 

(C) the percentage specified in paragraph (2)(B)(ii)(I) of such section is 
deemed to be 50 percent. 

(2) Allocation from increases in funding for part b.— For purposes of 
paragraph (1), the amount specified in this paragraph is the amount by which 
the amount appropriated under section 2677 of the Public Health Service Act 
for fiscal year 2001 and available for grants under section 2611 of such Act is 
an increase over the amount so appropriated and available for fiscal year 2000. 

SEC. 213. STUDY BY INSTITUTE OF MEDICINE. 

Subpart II of part B of title XXVI of the Public Health Service Act (42 U.S.C. 
300ff-33 et seq.) is amended by adding at the end the following section: 

"SEC. 2630. RECOMMENDATIONS FOR REDUCING INCD3ENCE OF PERINATAL TRANSMISSION. 

"(a) Study by Institute of Medicine.— 

"(1) In general.— The Secretary shall request the Institute of Medicine to 
enter into an agreement with the Secretary under which such Institute conducts 
a study to provide the following: 

"(A) For the most recent fiscal year for which the information is available, 
a determination of the number of newborn infants with HIV born in the 
United States with respect to whom the attending obstetrician for the birth 
did not know the HIV status of the mother. 

"(B) A determination for each State of any barriers, including legal bar- 
riers, that prevent or discourage an obstetrician from making it a routine 
practice to offer pregnant women an HIV test and a routine practice to test 
newborn infants for HIV disease in circumstances in which the obstetrician 
does not know the HIV status of the mother of the infant. 

"(C) Recommendations for each State for reducing the incidence of cases 
of the perinatal transmission of HIV, including recommendations on remov- 
ing the barriers identified under subparagraph (B). 
If such Institute declines to conduct the study, the Secretary shall enter into 
an agreement with another appropriate public or nonprofit private entity to con- 
duct the study. 

"(2) Report.— The Secretary shall ensure that, not later than 18 months after 
the effective date of this section, the study required in paragraph (1) is com- 
pleted and a report describing the findings made in the study is submitted to 
the appropriate committees of the Congress, the Secretary, and the chief public 
health official of each of the States. 
"(b) Progress Toward Recommendations.— Each State shall comply with the 
following (as applicable to the fiscal year involved): 

"(1) For fiscal year 2004, the State shall submit to the Secretary a report de- 
scribing the actions taken by the State toward meeting the recommendations 
specified for the State under subsection (a)(1)(C). 
"(2) For fiscal year 2005 and each subsequent fiscal year— 

"(A) the State shall make reasonable progress toward meeting such rec- 
ommendations; or 
"(B) if the State has not made such progress— 

"(i) the State shall cooperate with the Director of the Centers for Dis- 
ease Control and Prevention in carrying out activities toward meeting 
the recommendations; and 

"(ii) the State shall submit to the Secretary a report containing a de- 
scription of any barriers identified under subsection (a)(1)(B) that con- 
tinue to exist in the State; as applicable, the factors underlying the con- 
tinued existence of such barriers; and a description of how the State 
intends to reduce the incidence of cases of the perinatal transmission 
of HIV. 

"(c) Submission of Reports to Congress.— The Secretary shall submit to the ap- 
propriate committees of the Congress each report received by the Secretary under 
subsection (b)(2)(B)(ii).". 

Subtitle C— Certain Partner Notification 
Programs 

SEC. 221. GRANTS FOR COMPLIANT PARTNER NOTD7ICATTON PROGRAMS. 

Part B of title XXVI of the Public Health Service Act (42 U.S.C. 300ff-21 et seq.) 
is amended by adding at the end the following subpart: 



15 

"Subpart III— Certain Partner Notification Programs 

"SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS. 

"(a) In General.— In the case of States whose laws or regulations are in accord- 
ance with subsection (b), the Secretary, subject to subsection (cX2), may make 
grants to the States for carrying out programs to provide partner counseling and 
referral services. 

"(b) Description of Compliant State Programs.— For purposes of subsection 
(a), the laws or regulations of a State are in accordance with this subsection if under 
such laws or regulations (including programs carried out pursuant to the discretion 
of State officials) the following policies are in effect: 

"(1) The State requires that the public health officer of the State carry out 
a program of partner notification to inform partners of individuals with HIV 
disease that the partners may have been exposed to the disease. 

"(2XA) In the case of a health entity that provides for the performance on an 
individual of a test for HIV disease, or that treats the individual for the disease, 
the State requires, subject to subparagraph (B), that the entity confidentially 
report the positive test results to the State public health officer in a manner 
recommended and approved by the Director of the Centers for Disease Control 
and Prevention, together with such additional information as may be necessary 
for carrying out such program. 

"(B) The State may provide that the requirement of subparagraph (A) does 
not apply to the testing of an individual for HIV disease if the individual under- 
went the testing through a program designed to perform the test and provide 
the results to the individual without the individual disclosing his or her identity 
to the program. This subparagraph may not be construed as affecting the re- 
quirement of subparagraph (A) with respect to a health entity that treats an 
individual for HIV disease. 

"(3) The program under paragraph (1) is carried out in accordance with the 
following: 

"(A) Partners are provided with an appropriate opportunity to learn that 
the partners have been exposed to HIV disease, subject to subparagraph 

(B). 

"(B) The State does not inform partners of the identity of the infected in- 
dividuals involved. 

"(C) Counseling and testing for HIV disease are made available to the 
partners and to infected individuals, and such counseling includes informa- 
tion on modes of transmission for the disease, including information on pre- 
natal and perinatal transmission and preventing transmission. 

"(D) Counseling of infected individuals and their partners includes the 
provision of information regarding therapeutic measures for preventing and 
treating the deterioration of the immune system and conditions arising 
from the disease, and the provision of other prevention-related information. 

"(E) Referrals for appropriate services are provided to partners and in- 
fected individuals, including referrals for support services and legal aid. 

"(F) Notifications under subparagraph (A) are provided in person, unless 
doing so is an unreasonable burden on the State. 

"(G) There is no criminal or civil penalty on, or civil liability for, an in- 
fected individual if the individual chooses not to identify the partners of the 
individual, or the individual does not otherwise cooperate with such pro- 
gram. 

"(H) The failure of the State to notify partners is not a basis for the civil 
liability of any health entity who under the program reported to the State 
the identity of the infected individual involved. 

"(I) The State provides that the provisions of the program may not be 
construed as prohibiting the State from providing a notification under sub- 
paragraph (A) without the consent of the infected individual involved. 
"(4) The State annually reports to the Director of the Centers for Disease 
Control and Prevention the number of individuals from whom the names of 
partners have been sought under the program under paragraph (1), the number 
of such individuals who provided the names of partners, and the number of 
partners so named who were notified under the program. 

"(5) The State cooperates with such Director in carrying out a national pro- 
gram of partner notification, including the sharing of information between the 
public health officers of the States. 
"(c) Reporting System for Cases of HTV Disease.— 

"(1) Preference in making grants through fiscal year 2003.— In making 
grants under subsection (a) for each of the fiscal years 2001 through 2003, the 



16 



Secretary shall give preference to States whose reporting systems for cases of 
HIV disease produce data on such cases that is sufficiently accurate and reliable 
for use for purposes of section 2618(b)(2)(D)(i). 

"(2) Eligibility condition after fiscal year 2003.— For fiscal year 2004 and 
subsequent fiscal years, a State may not receive a grant under subsection (a) 
unless the reporting system of the State for cases of HIV disease produces data 
on such cases that is sufficiently accurate and reliable for purposes of section 
2618(b)(2)(D)(i). 

"(d) Authorization of Appropriations.— For the purpose of carrying out this 
section, there are authorized to be appropriated $30,000,000 for fiscal year 2001, 
and such sums as may be necessary for each of the fiscal years 2002 through 2005.". 

TITLE III— EARLY INTERVENTION SERVICES 
Subtitle A— Formula Grants for States 

SEC. 301. REPEAL OF PROGRAM. 

Subpart I of part C of title XXVI of the Public Health Service Act (42 U.S.C. 
300ff-41 et seq.) is repealed. 

Subtitle B— Categorical Grants 

SEC. 311. PREFERENCES IN MAKING GRANTS. 

Section 2653 of the Public Health Service Act (42 U.S.C. 300ff-53) is amended by 
adding at the end the following subsection: 

"(d) Underserved and Rural Areas.— Of the applicants who qualify for pref- 
erence under this section, the Secretary shall give preference to applicants that will 
expend the grant under section 2651 to provide early intervention under such sec- 
tion in rural areas or in areas that are underserved with respect to such services.". 

SEC. 312. PLANNING AND DEVELOPMENT GRANTS. 

(a) In General. -Section 2654(c)(1) of the Public Health Service Act (42 U.S.C. 
300ff-54(c)(l)) is amended by striking "planning grants" and all that follows and in- 
serting the following: "planning grants to public and nonprofit private entities for 
purposes of— 

"(A) enabling such entities to provide HIV early intervention services; and 
"(B) assisting the entities in expanding their capacity to provide HTV-re- 
lated health services, including early intervention services, in low-income 
communities and affected subpopulations that are underserved with respect 
to such services (subject to the condition that a grant pursuant to this sub- 
paragraph may not be expended to purchase or improve land, or to pur- 
chase, construct, or permanently improve, other than minor remodeling, 
any building or other facility).". 

(b) Amount; Duration.— Section 2654(c) of the Public Health Service Act (42 
U.S.C. 300ff-54(c)) is further amended- 

(1) by redesignating paragraph (4) as paragraph (5); and 

(2) by inserting after paragraph (3) the following: 
"(4) Amount and duration of grants.— 

"(A) Early intervention services.— A grant under paragraph (1)(A) 
may be made in an amount not to exceed $50,000. 
"(B) Capacity development. — 

"(i) Amount.— A grant under paragraph (1)(B) may be made in an 
amount not to exceed $150,000. 

"(ii) Duration.— The total duration of a grant under paragraph 
(1)(B), including any renewal, may not exceed 3 years.". 

(c) Increase in Limitation.— Section 2654(cX5) of the Public Health Service Act 
(42 U.S.C. 300ff-54(c)(5)), as redesignated by subsection (b), is amended by striking 
"1 percent" and inserting "5 percent". 

SEC. 313. AUTHORIZATION OF APPROPRIATIONS. 

Section 2655 of the Public Health Service Act (42 U.S.C. 300ff-55) is amended by 
striking "in each of and all that follows and inserting "for each of the fiscal years 
2001 through 2005.". 



17 

Subtitle C— General Provisions 



SEC. 321. PROVISION OF CERTAIN COUNSELING SERVICES. 

Section 2662(c)(3) of the Public Health Service Act (42 U.S.C. 300ff-62(c)(3)) is 
amended— 

(1) in the matter preceding subparagraph (A), by striking "counseling on—" 
and inserting "counseling—"; 

(2) in each of subparagraphs (A), (B), and (D), by inserting "on" after the sub- 
paragraph designation; and 

(3) in subparagraph CO- 

CA) by striking "(C) the benefits" and inserting "(C)(i) that explains the 
benefits"; and 

(B) by inserting after clause (i) (as designated by subparagraph (A) of this 
paragraph) the following clause: 

"(ii) that emphasizes it is the duty of infected individuals to disclose their 
infected status to their sexual partners and their partners in the sharing 
of hypodermic needles; that provides advice to infected individuals on the 
manner in which such disclosures can be made; and that emphasizes that 
it is the continuing duty of the individuals to avoid any behaviors that will 
expose others to HIV; 

SEC. 322. ADDITIONAL REQUIRED AGREEMENTS. 

Section 2664(g) of the Public Health Service Act (42 U.S.C. 300ff-64(g)) is 
amended— 

(1) in paragraph (3)— 

(A) by striking "7.5 percent" and inserting "10 percent"; and 

(B) by striking "and" after the semicolon at the end; 

(2) in paragraph (4), by striking the period and inserting "; and"; and 

(3) by adding at the end the following paragraph: 

"(5) the applicant will provide for the establishment of a quality management 
program to assess the extent to which medical services funded under this title 
that are provided to patients are consistent with the most recent Public Health 
Service guidelines for the treatment of HIV disease and related opportunistic 
infections and that improvements in the access to and quality of medical serv- 
ices are addressed.". 

TITLE IV— OTHER PROGRAMS AND ACTIVITIES 

Subtitle A— Certain Programs for Research, 
Demonstrations, or Training 

SEC. 401. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, IN- 
FANTS, CHILDREN, AND YOUTH. 

Section 2671 of the Public Health Service Act (42 U.S.C. 300ff-71) is amended- 

(1) in subsection (b)— 

(A) in paragraph (1), by striking subparagraphs (C) and (D) and inserting 
the following: 

"(C) The applicant will demonstrate linkages to research and how access 
to such research is being offered to patients."; and 

(B) by striking paragraphs (3) and (4); 

(2) in subsection (g), by adding at the end the following: "In addition, the Sec- 
retary, in coordination with the Director of such Institutes, shall examine the 
distribution and availability of appropriate HlV-related research projects with 
respect to grantees under subsection (a) for purposes of enhancing and expand- 
ing HIV-related research, especially within communities that are underrep- 
resented with respect to such projects."; 

(3) in subsection (f)— 

(A) by striking the subsection heading and designation and inserting the 
following: 

"(f) Administration. — 

"(1) Application.—"; and 

(B) by adding at the end the following paragraph: 

"(2) Quality management program.— A grantee under this section shall im- 
plement a quality management program."; and 

(4) in subsection (j), by striking "1996 through 2000" and inserting "2001 
through 2005". 



18 

SEC. 402. AIDS EDUCATION AND TRAINING CENTERS. 

(a) Schools; Centers.— 

(1) In GENERAL.— Section 2692(aXD of the Public Health Service Act (42 
U.S.C. 300ff-lll(aXD) is amended- 

(A) in subparagraph (A)— 

(i) by striking "training" and inserting "to train"; 

(ii) by striking "and including" and inserting ", including"; and 

(iii) by inserting before the semicolon the following: ", and including 
(as applicable to the type of health professional involved), prenatal and 
other gynecological care for women with HIV disease"; 

(B) in subparagraph (B), by striking "and" after the semicolon at the end; 

(C) in subparagraph (C), by striking the period and inserting "; and"; and 

(D) by adding at the end the following: 

"(D) to develop protocols for the medical care of women with HIV disease, 
including prenatal and other gynecological care for such women.". 

(2) Dissemination of treatment guidelines; medical consultation ac- 
tivities.— Not later than 90 days after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall issue and begin implementa- 
tion of a strategy for the dissemination of HIV treatment information to health 
care providers and patients. 

(b) Dental Schools. -Section 2692(b) of the Public Health Service Act (42 U.S.C. 
300ff-l 11(b)) is amended - 

(1) by amending paragraph (1) to read as follows: 
"(1) In general.— 

"(A) Grants.— The Secretary may make grants to dental schools and pro- 
grams described in subparagraph (B) to assist such schools and programs 
with respect to oral health care to patients with HIV disease. 

"(B) Eligible applicants.— For purposes of this subsection, the dental 
schools and programs referred to in this subparagraph are dental schools 
and programs that were described in section 777(bX4XB) as such section 
was in effect on the day before the date of enactment of the Health Profes- 
sions Education Partnerships Act of 1998 (Public Law 105-392) and in ad- 
dition dental hygiene programs that are accredited by the Commission on 
Dental Accreditation."; 

(2) in paragraph (2), by striking "777(bX4XB)" and inserting "the section re- 
ferred to in paragraph (1)(B)"; and 

(3) by inserting after paragraph (4) the following paragraph: 

"(5) Community-based care.— The Secretary may make grants to dental 
schools and programs described in paragraph (1XB) that partner with commu- 
nity-based dentists to provide oral health care to patients with HTV disease in 
unserved areas. Such partnerships shall permit the training of dental students 
and residents and the participation of community dentists as adjunct faculty.". 

(c) Authorization of Appropriations. — 

(1) Schools; centers.— Section 2692(cXD of the Public Health Service Act 
(42 U.S.C. 300ff-lll(cXD) is amended by striking "fiscal years 1996 through 
2000" and inserting "fiscal years 2001 through 2005". 

(2) Dental schools. -Section 2692(c)(2) of the Public Health Service Act (42 
U.S.C. 300ff-lll(cX2)) is amended to read as follows: 

"(2) Dental schools.— 

"(A) In general.— For the purpose of grants under paragraphs (1) 
through (4) of subsection (b), there are authorized to be appropriated such 
sums as may be necessary for each of the fiscal years 2001 through 2005. 

"(B) Community-based care.— For the purpose of grants under sub- 
section (b)(5), there are authorized to be appropriated such sums as may 
be necessary for each of the fiscal years 2001 through 2005.". 

Subtitle B- General Provisions in Title XXVI 

SEC. 411. evaluations and reports. 

Section 2674(c) of the Public Health Service Act (42 U.S.C. 300ff-74(c)) is amend- 
ed by striking "1991 through 1995" and inserting "2001 through 2005". 

SEC. 412. DATA COLLECTION THROUGH CENTERS FOR DISEASE CONTROL AND PREVENTION. 

Part D of title XXVI of the Public Health Service Act (42 U.S.C. 300ff-71 et seq.) 
is amended— 

(1) by redesignating section 2675 as section 2675A; and 

(2) by inserting after section 2674 the following section: 



19 



-SEC. 2675. DATA COLLECTION. 

"For the purpose of collecting and providing data for program planning and eval- 
uation activities under this title, there are authorized to be appropriated to the Sec- 
retary ' acting through the Director of the Centers for Disease Control and Preven- 
tion '"such sums as may be necessary for each of the fiscal years 2001 through 2005. 
Such authorization of appropriations is in addition to other authorizations of appro- 
priations that are available for such purpose.". 

SEC. 413. COORDINATION. 

Section 2675A of the Public Health Service Act. as redesignated by section 412 
of this Act, is amended— 

(1) by amending subsection <a> to read as follows: 
"(a) Requirement.— The Secretary shall ensure that the Health Resources and 
Services A dminis tration, the Centers for Disease Control and Prevention, the Sub- 
stance Abuse and Mental Health Services Admi ni stration, and the Health Care Fi- 
nancing Administration coordinate the planning,, funding, and implementation of 
Federal HIY programs to enhance the continuity of care and prevention services for 
individuals with HIY disease or those at risk of such disease. The Secretary shall 
consult with other Federal agencies, including the Department of Veterans Affairs, 
as needed and utilize planning information submitted to such agencies by the States 
and entities eligible for support."; 

<2' by redesignating subsections 'b> and (c) as subsections (c) and (d), respec- 
tively] 

(3) by inserting after subsection (b) the following subsection: 
"(b) Report.— The Secretary shall bie nnially prepare and submit to the appro- 
priate coinmittees of the Congress a report concerning the coordination efforts at the 
Federal. State, and local levels described in this section, including a description of 
Federal barriers to HIV program integration and a strategy for eliminating such 
barriers and enhancing the continuity of care and prevention services for individuals 
with HIY disease or those at risk of such disease.": and 

4' in each of subsections c and (d) 'as redesignated by paragraph (2) of this 
section.), by inserting "and prevention services" after "continuity of care" each 
place such term appears. 

SEC. 414. PLAN REGARDING RELEASE OF PRISONERS WITH HTV DISEASE, 

Section 2675A of the Public Health Service Act. as amended by section 413(2) of 
this Act. is amended by adding at the end the following subsection: 

"(e) Recommendations Regarding Release of Prisoners.— After consultation 
with the Attorney General and the Director of the Bureau of Prisons, with States, 
with eligible areas under part A, and with entities that receive amounts from grants 
under part A or B, the Secretary, consistent with the coordination required in sub- 
section (a), shall develop a plan for the medical case management of and the provi- 
sion of support services to individuals who were Federal or State prisoners and had 
HIY disease as of the date on which the individuals were released from the custody 
of the penal system. The Secretary shall submit the plan to the Congress not later 
than two years after the date of the enactment of the Ryan White CARE Act 
Amendments of 2000.". 

SEC. 415, AUDITS. 

Part D of title XXVI of the Public Health Service Act. as amended by section 412 
of this Act, is amended by inserting after section 2675A the following section: 

-SEC. 2675B. AUDITS, 

"For fiscal year 2002 and subsequent fiscal years, the Secretary may reduce the 
amounts of grants under this title to a State or political subdivision of a State for 
a fiscal year if, with respect to such grants for the second preceding fiscal year, the 
State or subdivision fails to prepare audits in accordance with the procedures of sec- 
tion 7502 of title 31, United States Code. The Secretary shall annually select rep- 
resentative samples of such audits, prepare summaries of the selected audits, and 
submit the summaries to the Congress.". 

SEC. 416, AD>ILNTSTRATTVE SIMPLIFICATION. 

Part D of title XXVI of the Public Health Service Act. as amended by section 415 
of this Act, is amended by inserting after section 2675B the following section: 

"^SEC 2675C. ADMLNISTRATTVE SLMPLTFICATION REGARDLNG PARTS A AND B. 

Coordinated Disbursement.— After consultation with the States, with eligi- 
ble areas under part A, and with entities that receive amounts from grants under 
part A or B, the Secretary shall develop a plan for coordinating the disbursement 
of appropriations for grants under part A with the disbursement of appropriations 
for grants under part B in order to assist grantees and other recipients of amounts 



20 



from such grants in complying with the requirements of such parts. The Secretary 
shall submit the plan to the Congress not later than 18 months after the date of 
the enactment of the Ryan White CARE Act Amendments of 2000. Not later than 
two years after the date on which the plan is so submitted, the Secretary shall com- 
plete the implementation of the plan, notwithstanding any provision of this title 
that is inconsistent with the plan. 

"(b) Biennial Applications. —After consultation with the States, with eligible 
areas under part A, and with entities that receive amounts from grants under part 
A or B, the Secretary shall make a determination of whether the administration of 
parts A and B by the Secretary, and the efficiency of grantees under such parts in 
complying with the requirements of such parts, would be improved by requiring that 
applications for grants under such parts be submitted biennially rather than annu- 
ally. The Secretary shall submit such determination to the Congress not later than 
two years after the date of the enactment of the Ryan White CARE Act Amend- 
ments of 2000. 

"(c) Application Simplification.— After consultation with the States, with eligi- 
ble areas under part A, and with entities that receive amounts from grants under 
part A or B, the Secretary shall develop a plan for simplifying the process for appli- 
cations under parts A and B. The Secretary shall submit the plan to the Congress 
not later than 18 months after the date of the enactment of the Ryan White CARE 
Act Amendments of 2000. Not later than two years after the date on which the plan 
is so submitted, the Secretary shall complete the implementation of the plan, not- 
withstanding any provision of this title that is inconsistent with the plan.". 

SEC. 417. AUTHORIZATION OF APPROPRIATIONS FOR PARTS A AND B. 

Section 2677 of the Public Health Service Act (42 U.S.C. 300ff-77) is amended to 
read as follows: 

"SEC. 2677. AUTHORIZATION OF APPROPRIATIONS. 

"(a) Part A.— For the purpose of carrying out part A, there are authorized to be 
appropriated such sums as may be necessary for each of the fiscal years 2001 
through 2005. 

"(b) Part B.— For the purpose of carrying out part B, there are authorized to be 
appropriated such sums as may be necessary for each of the fiscal years 2001 
through 2005.". 

TITLE V- GENERAL PROVISIONS 

SEC. 501. STUDIES BY INSTITUTE OF MEDICINE. 

(a) State Surveillance Systems on Prevalence of HIV.— The Secretary of 
Health and Human Services (referred to in this section as the "Secretary") shall re- 
quest the Institute of Medicine to enter into an agreement with the Secretary under 
which such Institute conducts a study to provide the following: 

(1) A determination of whether the surveillance system of each of the States 
regarding the human immunodeficiency virus provides for the reporting of cases 
of infection with the virus in a manner that is sufficient to provide adequate 
and reliable information on the number of such cases and the demographic 
characteristics of such cases, both for the State in general and for specific geo- 
graphic areas in the State. 

(2) A determination of whether such information is sufficiently accurate for 
purposes of formula grants under parts A and B of title XXVI of the Public 
Health Service Act. 

(3) With respect to any State whose surveillance system does not provide ade- 
quate and reliable information on cases of infection with the virus, rec- 
ommendations regarding the manner in which the State can improve the sys- 
tem. 

(b) Relationship Between Epidemiological Measures and Health Care for 
Certain Individuals With HIV Disease.— 

(1) In general.— The Secretary shall request the Institute of Medicine to 
enter into an agreement with the Secretary under which such Institute conducts 
a study concerning the appropriate epidemiological measures and their relation- 
ship to the financing and delivery of primary care and health-related support 
services for low-income, uninsured, and under-insured individuals with HIV dis- 
ease. 

(2) Issues to be considered.— The Secretary shall ensure that the study 
under paragraph (1) considers the following: 



21 

(A) The availability and utility of health outcomes measures and data for 
HIV primary care and support services and the extent to which those meas- 
ures and data could be used to measure the quality of such funded services. 

(B) The effectiveness and efficiency of service delivery (including the qual- 
ity of services, health outcomes, and resource use) within the context of a 
changing health care and therapeutic environment, as well as the changing 
epidemiology of the epidemic, including determining the actual costs, poten- 
tial savings, and overall financial impact of modifying the program under 
title XIX of the Social Security Act to establish eligibility for medical assist- 
ance under such title on the basis of infection with the human immuno- 
deficiency virus rather than providing such assistance only if the infection 
has progressed to acquired immune deficiency syndrome. 

(C) Existing and needed epidemiological data and other analytic tools for 
resource planning and allocation decisions, specifically for estimating sever- 
ity of need of a community and the relationship to the allocations process. 

(D) Other factors determined to be relevant to assessing an individual's 
or community's ability to gain and sustain access to quality HIV services. 

(c) Other Entities.— If the Institute of Medicine declines to conduct a study 
under this section, the Secretary shall enter into an agreement with another appro- 
priate public or nonprofit private entity to conduct the study. 

(d) Report.— The Secretary shall ensure that— 

(1) not later than three years after the date of the enactment of this Act, the 
study required in subsection (a) is completed and a report describing the find- 
ings made in the study is submitted to the appropriate committees of the Con- 
gress; and 

(2) not later than two years after the date of the enactment of this Act, the 
study required in subsection (b) is completed and a report describing the find- 
ings made in the study is submitted to such committees. 

SEC. 502. DEVELOPMENT OF RAPID HIV TEST. 

(a) Expansion, Intensification, and Coordination of Research and Other 
Activities. — 

(1) In general.— The Director of NIH shall expand, intensify, and coordinate 
research and other activities of the National Institutes of Health with respect 
to the development of reliable and affordable tests for HIV disease that can rap- 
idly be administered and whose results can rapidly be obtained (in this section 
referred to a "rapid HIV test"). 

(2) Report to congress.— The Director of NIH shall periodically submit to 
the appropriate committees of Congress a report describing the research and 
other activities conducted or supported under paragraph (1). 

(3) Authorization of appropriations.— For the purpose of carrying out this 
subsection, there are authorized to be appropriated such sums as may be nec- 
essary for each of the fiscal years 2001 through 2005. 

(b) Premarket Review of Rapid HIV Tests. — 

(1) In general.— Not later than 90 days after the date of the enactment of 
this Act, the Secretary, in consultation with the Director of the Centers for Dis- 
ease Control and Prevention and the Commissioner of Food and Drugs, shall 
submit to the appropriate committees of the Congress a report describing the 
progress made towards, and barriers to, the premarket review and commercial 
distribution of rapid HIV tests. The report shall— 

(A) assess the public health need for and public health benefits of rapid 
HIV tests, including the minimization of false positive results through the 
availability of multiple rapid HTV tests; 

(B) make recommendations regarding the need for the expedited review 
of rapid HIV test applications submitted to the Center for Biologies Evalua- 
tion and Research and, if such recommendations are favorable, specify cri- 
teria and procedures for such expedited review; and 

(C) specify whether the barriers to the premarket review of rapid HIV 
tests include the unnecessary application of requirements— 

(i) necessary to ensure the efficacy of devices for donor screening to 
rapid HIV tests intended for use in other screening situations; or 

(ii) for identifying antibodies to HTV subtypes of rare incidence in the 
United States to rapid HIV tests intended for use in screening situa- 
tions other than donor screening. 

(c) Guidelines of Centers for Disease Control and Prevention.— Promptly 
after commercial distribution of a rapid HIV test begins, the Secretary, acting 
through the Director of the Centers for Disease Control and Prevention, shall estab- 
lish or update guidelines that include recommendations for States, hospitals, and 
other appropriate entities regarding the ready availability of such tests for adminis- 



22 



tration to pregnant women who are in labor or in the late stage of pregnancy and 
whose HIV status is not known to the attending obstetrician. 

TITLE VI -EFFECTIVE DATE 

SEC. 601. EFFECTIVE DATE. 

This Act and the amendments made by this Act take effect October 1, 2000, or 
upon the date of the enactment of this Act, whichever occurs later. 

Purpose and Summary 

The Ryan White CARE Act Amendments of 2000 reauthorizes 
programs providing for the comprehensive health care of Ameri- 
cans suffering from HIV/AIDS and prevention programs to prevent 
the spread of HIV. 

Background and Need for Legislation 

Acquired Immunodeficiency Syndrome (AIDS) cases were first re- 
ported in the United States in 1981. In the two decades since, more 
than 700,000 persons in the United States have been diagnosed 
with AIDS. The General Accounting Office (GAO) recently esti- 
mated that by the end of 1998, 300,000 persons in the United 
States were living with AIDS, and that as many as hundreds of 
thousands of people in this country are infected with the human 
immunodeficiency virus (HIV), but have not yet progressed to 
AIDS. 

Because persons with AIDS faced problems obtaining insurance 
coverage and access to primary care and support, the Congress re- 
sponded in 1990 by passing the Ryan White Comprehensive AIDS 
Resources Emergency (CARE) Act (P.L. 101-381). The framework 
of that Act, as passed, continues in force today. 

Title I of the Act provides relief to eligible metropolitan areas 
(EMAs) disproportionately impacted by AIDS. By fiscal year (FY) 
1991, there were 16 EMAs receiving CARE Act Title I funding. 
Currently, as of FY2000, there are 51 EMAs. Title I relief is pro- 
vided through formula and supplemental grants to be used for case 
management and comprehensive treatment services, among other 
things. Such grants are intended to supplement, not supplant, 
State funding, and have the express purpose of delivering or en- 
hancing HIV-related outpatient and ambulatory health and support 
services. These service include case management, substance abuse 
and mental health treatment, comprehensive treatment services, 
and inpatient case management services that prevent unnecessary 
hospitalization or that expedite discharges. 

As originally enacted in 1990, a community was entitled to be an 
EMA if the area had more than 2,000 cases of AIDS, or if the cu- 
mulative per capita incidence of AIDS exceeded one quarter of one 
percent. Under the Ryan White CARE Act Amendments of 1996 
(P.L. 104-186), this was changed so that areas could qualify for 
funding under Title I if the area has a population of 500,000 or 
more individuals, and the area has reported to the Director of the 
Centers for Disease Control and Prevention (CDC) a cumulative 
total of more than 2,000 cases of AIDS for the most recent five cal- 
endar years. 

Title I funding is, generally, equally divided amongst formula 
and supplemental grants. Formula grants are distributed to EMAs 



23 



according to a complex distribution factor, taking into account the 
estimated living number of AIDS cases in the EMA. The estimated 
living number of AIDS cases in an EMA is determined by the num- 
ber of AIDS cases reported to, and confirmed by, the CDC in the 
most recent ten year period, multiplied (on a yearly basis) by a per- 
centage developed by the Secretary of the Department of Health 
and Human Services. Title I supplemental grants are awarded 
based upon severe need, though these grants have been awarded 
historically in a way which results in a doubling of the Title I for- 
mula amount. 

One important exception must be noted. The 1990 CARE Act dis- 
tributed formula funds based partially upon the historical number 
of AIDS cases the EMA had experienced, irrespective of whether 
the disease sufferers were still alive. The 1996 CARE Act Amend- 
ments altered this to allocate funds based upon living number of 
AIDS cases. Because the change from historic incidences of AIDS 
to estimated living AIDS cases per EMA could have caused signifi- 
cant disruptions in funding received by certain EMAs, the 1996 
CARE Act Amendments contained a "hold harmless" clause. Ac- 
cording to this provision, no EMA could lose more than five per- 
cent, over five years, from the EMA's FY1995 Title I formula grant. 
To fund the "hold harmless" provision, the amount of Title I sup- 
plemental grant funds available to all EMAs is reduced accord- 
ingly. 

Title I grants are made to the chief elected official of the city or 
county in the EMA that administers the health agency providing 
services to the greatest number of persons with AIDS. This chief 
elected official must establish or designate an HIV health services 
planning council to establish priorities for care delivery according 
to Federal guidelines, in order to receive Title I funds. Members of 
the councils must reflect the demographics of the epidemic in the 
EMA, and it shall include representatives of health care providers; 
community-based organizations serving affected populations and 
AIDS service organizations; affected communities, including people 
with HIV disease or AIDS, and historically underserved groups and 
subpopulations; mental health and substance abuse providers, and 
others. The council may not be directly involved in the administra- 
tion of any Title I grant. 

Title II funds provide formula grants to states and territories for 
comprehensive care services including home and community-based 
health care and support services. States use such funds to provide 
services directly or through contracts with HIV care consortia. Title 
II grants are also used to provide health insurance coverage for 
low-income persons through Health Insurance Continuation Pro- 
grams and drug treatments for individuals with HIV and AIDS 
who have limited or no coverage from private insurance or Med- 
icaid through AIDS Drug Assistance Programs (ADAPs). Prior to 
FY1996, States determined the amount of their Title II funds they 
would dedicate to ADAPs. In FY1996, Congress began appro- 
priating ADAP-targeted funds under Title II. 

Grants are awarded to States based upon a weighted formula 
that accounts for two factors: (1) the estimated number of living 
AIDS cases in the State; and (2) the estimated number of living 
AIDS cases in the State who are not in a Title I EMA. States with 
more than 1% of the total AIDS cases reported nationally must 



24 



contribute State matching funds based on a formula, and grants 
may not be made to any State that does not make a good faith ef- 
fort to notify a spouse of an HIV-infected patient that the spouse 
should seek testing. 

Further, Title II provides up to $10 million for States which cer- 
tify that they have in effect regulations or measures to adopt CDC 
guidelines concerning HIV virus counseling and voluntary testing 
for pregnant women. Priority is given to States that have the great- 
est proportion of HIV seroprevalance among child bearing women, 
as determined by the CDC. 

Early intervention services are provided for under Title III of the 
CARE Act. Under this, public and private nonprofit entities already 
providing primary care services to low-income and medically under- 
served populations compete for grants to provide HIV testing, risk 
reduction counseling, case management, outreach, medical evalua- 
tion, transmission prevention, oral health, nutritional and mental 
health services, and clinical care. Community health centers, home- 
less programs, local health departments, family planning programs, 
hemophilia diagnostic and treatment centers, as well as other non- 
profit community-based programs all compete for Title III grants. 

When enacted in 1990, Title IV authorized a number of different 
HIV-related programs, but the only one for which funds were ap- 
propriated was pediatric demonstration grants. In the 1996 CARE 
Act Amendments, this funded program was replaced with a pro- 
gram of grants for coordinated services and access to research for 
women, infants, children and youth. Such grants provide opportu- 
nities for women, infants, children and youth to be voluntary par- 
ticipants in research of potential clinical benefit to individuals with 
HIV and AIDS. Such individuals are provided access to health care 
on an outpatient basis, case management, referrals, transportation, 
child care, and other services which enable participation. 

Other programs under the CARE Act which have been funded in- 
clude special projects of national significance for the care and treat- 
ment of individuals with HIV/AIDS, AIDS Education and Training 
Centers program (AETC), and the AIDS Dental Reimbursement 
program. 

Funding Fairness. The Committee has amended and enhanced 
the CARE Act to respond to significant changes in the HIV/AIDS 
epidemic. It is important to the Committee that no eligible metro- 
politan area lose its ability to provide services authorized under the 
CARE Act. At the same time, it is equally important to the Com- 
mittee that no EMA receive significantly more Title I formula fund- 
ing on a per case basis than other similarly-situated EMAs. 

It is the Committee's intention that, over time, each EMA should 
receive Title I formula funds in proportion to its estimated number 
of living HIV cases. The GAO has reported, however, that presently 
one EMA, the San Francisco EMA, receives dramatically more Title 
I funding on a per case basis than any other EMA. For example, 
GAO reports that in FY 1999 San Francisco spent $5,598 per AIDS 
case, while the other 50 EMAs spent between $2,509 and $3,132 
per AIDS case. More specifically, GAO reported that the San Fran- 
cisco EMA receives roughly 80% more per in Title I grant funds per 
AIDS case than other EMAs. 



25 



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A few have defended this disparity by stating that per patient 
cost is higher than other places because the costs of care in services 
in the Bay Area is so inflated. But even if CARE Act money were 
adjusted for funding the cost of providing medical care (it presently 
is not), San Francisco still receives far more than any other EMA 
per capita. The accompanying graph uses the Medicare hospital 
cost wage index cost adjuster on the per capita Title I formula and 
discretionary grant money used in chart 1. Even with these adjust- 
ments, it is clear that the San Francisco EMA still gets the most 
of all EMAs. With similar cost structures as San Francisco, Oak- 
land and San Jose in the Bay Area join New York at the bottom 
of Title I funding. 



27 



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28 



The present disparity in funding results from the way EMAs 
were funded under Title I when the CARE Act was enacted in 
1990. Originally, EMAs were funded based upon the cumulative 
number of AIDS cases the EMA experienced. In 1996, Title I for- 
mula funding was altered to compensate EMAs based upon the es- 
timated number of living AIDS cases in the EMA, rather than the 
cumulative caseload of living and dead AIDS cases. So that certain 
EMAs would not find their Title I formula funding dramatically de- 
creased, a hold harmless provision was included in the reauthoriza- 
tion limiting funding cuts to no more than five percent, over five 
years, from the 1995 Title I formula amount. 

The GAO reports that presently only the San Francisco EMA 
benefits from this hold harmless provision, thus explaining the dis- 
parity in funding. During the July 11, 2000 hearing before the Sub- 
committee on Health and Environment, the GAO acknowledged 
that a reason for this is that San Francisco's basis of funding, due 
to the hold harmless, still compensates the EMA for individuals 
who have long ago died. 

To ensure that per case funding is more equitable, H.R. 4807 re- 
forms the hold harmless provision which limits funding reductions 
to EMAs. According to the provision in this bill, no EMA would ex- 
perience a reduction greater than 25% of its base year formula allo- 
cation over the next five fiscal years. Such a regime would still 
leave the San Francisco EMA with more Title I formula funds on 
a per case basis than any other EMA, while still alleviating some 
of the unfair funding disparities. 

As a way to protect State funding provided by Title II, the legis- 
lation contains a hold harmless provision which ensures that no 
State will see more than a one percent cut in Title II formula funds 
per fiscal year. This reflects a continuation of present law. It is im- 
portant to note that no State has benefitted from this provision 
since its enactment. 

The Committee intends that Title I supplemental awards are not 
intended to be allocated on the basis of formula grant allocations. 
Instead, such supplemental awards are to be directed to those eligi- 
ble areas with "severe need," or the greatest or expanding public 
health challenges in confronting the epidemic. The Committee has 
included additional factors to be considered in the assessment of se- 
vere need, including the current prevalence of HIV/AIDS, and the 
degree of increasing and unmet needs for services. Additionally, the 
Committee believes that syphilis, hepatitis B and hepatitis C 
should be regarded as important co-morbidities to HIV/AIDS. 

It is the Committee's strong view that HRSA's Bureau of HIV/ 
AIDS should employ standard, quantitative measures to the max- 
imum extent possible in lieu of narrative self-reporting when 
awarding supplemental awards. The Committee renews the Bu- 
reau's obligation to develop in a timely manner a mechanism for 
determining severe need upon the basis of national, quantitative 
incidence data. In this regard, the Committee recognizes that ade- 
quate and reliable data on HIV prevalence may not be uniformly 
available in all eligible areas on the date of enactment. The Com- 
mittee also notes that "HIV disease" under the CARE Act encom- 
passes both persons living with AIDS as well as persons diagnosed 
as HIV positive who have not developed AIDS. 



29 



Just as importantly, for the first time the CARE Act will recog- 
nize the need for Title II supplemental grants with the passage of 
H.R. 4807. These grants are intended for areas, other than EMAs, 
experiencing a severe need for supplemental financial assistance. 
Like with Title I supplemental awards, it is the Committee's inten- 
tion that Title II supplemental awards should not be allocated in 
proportion to formula awards, but rather on the basis of dem- 
onstrated severe need. 

The Committee intends that preference should be given to shift 
Title III grants to addressing the needs of rural areas and under- 
served areas. This preference is intended to further shift CARE Act 
programs towards eliminating disparities in access and services 
among affected subpopulations and historically underserved com- 
munities. 

The Committee strongly supports the use of Title I funds to con- 
duct outreach activities to identify individuals with HIV/AIDS who 
are not receiving services, and get them under medical care and 
treatment. President Reagan's HIV Commission concluded that 
"early diagnosis of HIV infection is essential" because HIV infection 
"can be treated more effectively when detected early." The Com- 
mittee concurs with these findings and acknowledges that the med- 
ical breakthroughs which have been developed in the twelve years 
since the issuance of this report make early intervention even more 
important. This authorization reflects the Committee's intent to in- 
crease the coordination between HIV prevention and HIV care and 
treatment services in all CARE Act programs. The Committee ex- 
pects such activities will be of particular importance when focusing 
on underserved populations, and of particular value in bringing 
into and retain in care those individuals who are knowledgeable of 
their status but are not receiving services. 

HIV Reporting. According to CDC, in June 1999 there were an 
estimated 287,946 Americans living with AIDS. Currently, CDC is 
not able to determine how many Americans were living with HIV, 
because only 29 states report HIV cases. CDC expects all states to 
be reporting newly diagnosed HIV cases by 2003 and than an addi- 
tional 1 to 3 years may be needed to get all HIV cases entered into 
such new reporting systems. It is difficult for regions without reli- 
able HIV surveillance to adequately address the needs or under- 
stand the scope of the epidemic. 

The identification of HIV reporting as a serious public health 
concern was identified by the first Presidential Commission on 
HIV, appointed by President Reagan, which issued the "Report of 
the Presidential Commission on the Human Immunodeficiency 
Virus Epidemic" on June 24, 1988. According to that report: 

The term "AIDS" is obsolete. "HIV infection" more cor- 
rectly defines the problem. The medical, public health, po- 
litical, and community leadership must focus on the full 
course of HIV infection rather than concentrating on later 
stages of the disease (ARC and AIDS). Continual focus on 
AIDS rather than the entire spectrum of HIV disease has 
left our nation unable to deal adequately with the epi- 
demic. Federal and state data collection efforts must now 
be focused on early HIV reports, while still collecting data 
on symptomatic disease. 



30 



Eleven and a half years later, the CDC has implemented pro- 
posals consistent with proposals made by President Reagan's Com- 
mission on the Human Immunodeficiency Virus Epidemic. 

To address the challenge of insufficient value being derived from 
AIDS data alone, CDC joined the Council of State and Territorial 
Epidemiologists (CSTE) to recommend in December 1999 that all 
states and territories include name surveillance for HIV infection 
as an extension of their AIDS surveillance activities. On May 11, 
2000, 

Surgeon General Satcher testified before the Subcommittee on 
Health and Environment that he agreed with the CDC and CSTE 
recommendation. In light of the consensus that has finally 
emerged, the Committee believes all jurisdictions should shift the 
focus from AIDS to the full spectrum of HIV infection for improved 
prevention and care. Federal funding as well should be based upon 
the full extent of the disease rather than only on the late stages 
defined as AIDS. This will ensure more equitable funding and more 
timely and appropriate responses. 

The consequences and human toll of dithering over HIV report- 
ing over the last decade has been high, and not just in this country. 
The Committee believes that other public health institutions 
throughout the world have not yet adopted HIV reporting, and for 
this reason the Committee strongly recommends that the CDC 
should work in consultation with HRSA on all international HIV/ 
AIDS initiatives to avoid repeating mistakes made in the past. The 
Committee is also concerned that, because public health institu- 
tions had no data to show the rate of growth of HIV cases among 
various American cultural and ethnic communities, communities of 
color are disproportionately affected and infected by the HIV epi- 
demic. 

HIV Case Classification. The Committee is aware of concerns 
that the heterosexual and NIR categories as currently defined may 
result in systematic underreporting of heterosexual cases of HIV, 
which could be detrimental to addressing the prevention needs of 
certain groups, particularly communities of color. 

This classification system may have been satisfactory early in 
the epidemic, but the changing dynamics of the HIV/AIDS epidemic 
require a timely reassessment and refinement of current classifica- 
tion methods. The Committee applauds the CDC's recognition of 
State efforts to accomplish these goals, including Virginia's efforts 
to identify NIR cases with multiple sex partners. The CDC has in- 
dicated that it is also currently reassessing HIV/AIDS case classi- 
fication methods to ensure the most adequate understanding of the 
disease and its modes of transmission and to properly allocate and 
target resources to those groups that are increasingly at risk of in- 
fection, such as African American females. 

Based on this understanding, the Committee urges the Secretary 
to commit to an agenda of coordinated actions with the States and 
patient advocates, including the development and validation of rig- 
orous sampling techniques, the promulgation of formal guidance to 
the States, the provision of technical assistance to State and local 
health authorities, and the expansion of the CDC's current pilot 
projects with interested States. Finally, the Committee applauds 
the CDC's commitment to hold a public meeting to obtain expert 



31 



opinion on this issue, and its current efforts to consult with the 
Committee prior to the meeting regarding its attendance. 

Demographics and Needs of Populations with HIV Disease. The 
comprehensive service delivery plan is an effective way to dem- 
onstrate the organization and delivery of CARE Act services based 
upon the planning, priority setting, and funding allocation proc- 
esses conducted by the planning council. The intent of the legisla- 
tion is also to have the additional factors reflected in the plan. 
Those factors include disparities in access to medical and health- 
related support services by specific subpopulations; the needs of 
persons with HIV not in care; capacity development needs; and 
quality of HIV primary care and health-related supportive services. 
Both the planning process and the resulting plan should include 
the participation of, and address the needs of, populations and sub- 
populations living with HIV and AIDS. 

The Committee requires that Planning Councils determine the 
size, demographics and needs of the population with HIV disease. 
The Committee recognizes that adequate and reliable data on HIV 
prevalence may not be uniformly available in all eligible areas on 
the date of enactment. Therefore, priorities for the allocation of 
funds and the comprehensive plan should reflect HIV prevalence to 
the extent that data are reasonably available. The Committee also 
notes that "HTV disease" under the CARE Act encompasses both 
persons living with AIDS as well as persons diagnosed as HIV posi- 
tive who have not developed AIDS. 

The reauthorization bill reflects the Committee position that pri- 
ority setting and funding allocation decisions should be based on 
the size and demographic characteristics of the populations with 
HIV disease in the eligible area. Planning, priority setting, and 
funding allocation processes must take into account shifts in the 
local HIV/AIDS epidemic, existing health HIV-related disparities, 
and resulting negative health outcomes. 

The Committee intends Planning Councils to develop a strategy 
to identify individuals with HIV disease who are not receiving serv- 
ices and to inform and enable such individuals to receive services 
under Title I. The Committee wants CARE Act providers to work 
actively to bring into and retain in care those individuals who are 
unaware of their HIV status and those who are knowledgeable of 
their status but are not receiving services. As part of this process, 
the Committee believes strongly in the importance of Planning 
Councils focusing on eliminating disparities in access and services 
among affected subpopulations and historically underserved com- 
munities. The Committee recognizes that the availability or lack of 
HIV prevalence data in particular EMAs will be reflected in the 
scope, goals, timetable and allocation of funds for implementation 
of the strategy. 

The Committee also intends Planning Councils to develop a 
strategy to coordinate the provision of Title I services with HIV 
prevention services and substance abuse prevention and treatment 
services. The Committee has amended numerous aspects of CARE 
Act programs to enhance the coordination between HIV prevention 
and HIV care and treatment services. The Committee further re- 
quests that the Secretary work with title I grant recipients and 
providers to establish epidemiologic measures and tools for use by 



32 



EMAs in identifying the number of individuals with HIV infection, 
especially those who are not in care. 

The Committee expects that the development of such measures 
will refine and expand the ability of EMAs and Planning Councils 
to identify and provide services to individuals with HIV disease 
who are not receiving services. The efforts on the part of EMAs and 
Planning Councils to accomplish these important tasks, however, 
should not be delayed until this process is complete. Instead, the 
Committee expects EMAs and Planning Councils to establish and 
implement strategies responsive to these urgent needs before the 
development of nationally uniform measures, to the extent that is 
practicable and to which necessary prevalence data is reasonably 
available. 

Early Intervention Services. The Committee authorizes early 
intervention services as eligible services under certain cir- 
cumstances in Titles I and II. The Committee intends to allow 
grantees to provide certain early intervention services, such as HIV 
counseling, testing, and referral services, to individuals at high risk 
for HIV infection in accordance with statewide planning and re- 
gional consortia planning activities. Additionally, the Committee 
intends that the types of organizations that may provide early 
intervention services are the same as those that provide other HIV- 
related services through Parts B or C of the Act, or are points of 
access into the health care system for individuals at high risk for 
HIV, as specified by States under guidance from HRSA's Bureau 
of HIV/AIDS. 

The Committee recognizes that these organizations may include 
traditional community based organizations (CBOs) that act as 
points of entry and/or referral agencies into the health care system, 
especially for traditionally underserved and minority populations. 
This provision is solely for the purpose of expanding the scope of 
primary care services to include HIV testing, counseling, and refer- 
ral. The Committee recognizes the importance of early intervention 
services in increasing access to medical services through estab- 
lished relations with a broad network of health care entry points 
and HIV medical providers that serve as critical entry points for 
medical services for uninsured, and underinsured, low-income and 
rural communities. The Committee specifically intends that funds 
not be used to supplant other funds available to States for the pro- 
vision of early intervention services and that these funds are uti- 
lized only when existing Federal, State or local funds are inad- 
equate to provide these services. Further, the Committee intends 
that such services need to be provided according to guidelines es- 
tablished by the CDC and according to the laws and administrative 
regulations of State and local governments. The Committee expects 
that the Secretary, working with grantees and the public health 
community, will provide guidance to establish the appropriate pa- 
rameters for the use of CARE Act funds for these purposes and to 
coordinate these activities with existing early intervention services. 
The Committee recognizes that other funding sources may exist for 
these services and expects all grantees to seek out and use these 
funds to enhance medical care to the extent they are reasonably 
available. 

The Committee finds that all counseling for HIV-infected individ- 
uals should emphasize that it is the duty of infected individuals to 



33 



disclose their infected status to their sexual partners and others 
who are they potentially may place at risk of infection. The Com- 
mittee recognizes that proper counseling better enables individuals 
living with fctiV to make such disclosures. The Committee intends 
for entities providing care under this legislation will provide such 
counseling and emphasize that it is the continuing duty of the in- 
fected individuals to avoid anv behaviors that will expose others to 

rav. 

The Committee heard testimony in 1998 from an iilV infected 
man who became infected because his partner hid his HIV status 
and did so after counseling from Federally supported organizations 
which did not advise him to disclose. The Co mm ittee believes that 
this policy all those who are infected should be provided proper ad- 
vice to disclose and provided the counseling to do so. Recent studies 
have found that the continuing epidemic in the United States is 
being driven by infected individuals who do not disclose their sta- 
tus and continue to engage in risky behaviors. The Committee be- 
lieves that existing prevention policies have failed to adequately 
address such behavior and have enabled them to continue. This 
provision will provide better secondary prevention and protect the 
infected from other health complications including dual HIV infec- 
tion. 

Rapid HIV lest. The Committee also seeks to expand and coordi- 
nate efforts at the NTH and FDA to develop rapid HIV tests. Accu- 
rate and affordable rapid HIV tests have many potentially impor- 
tant applications, one of which would be to help diagnose pregnant 
women whose HIV status is not known late in pregnancy or at the 
time of labor. The purpose of this initiative is to help increase op- 
portunities for mdrviduals. including pregnant women, to learn 
their HIV status. The Committee recognizes that labor is not an 
ideal time to obtain consent for testing or to discuss the implica- 
tions of a positive test result, It is not the intent of this Committee 
to diminish the right of patients to make an informed decision to 
be tested. In establishing or updating relevant guidelines. CDC 
should address how to ensure that the meaningful decision making 
ability of patients is preserved. These guidelines should recognize 
that states have varying laws and policies related to the commu- 
nication of test results. The Committee encourages the FDA to fa- 
cilitate CDC's ability to use rapid HIV tests as soon as possible, 
consistent with the FDA's approval process. 

Partner Notification, The results of various regional studies con- 
firm that partner notification is a useful and effective intervention 
and prevention tool. Infected individuals are less likely to notify 
artners themselves, but will cooperate with programs conducted 
y public health professionals. Studies and surveys have also con- 
e.uded that partners notified about potential exposure to HIV sup- 
port notification programs. 

The Presidential Commission on HIV stated, "public health au- 
thorities across the United States must begin immediately to insti- 
tute confidential partner notification, the system by which intimate 
contacts of the person earning sexually transmitted diseases, in- 
cluding HIV. are warned of their exposure." 

Partner notification has proven to be highly effective. Up to 90 
percent of these who test positive cooperate voluntarily with notifi- 
cation. Further, even higher proportions of those partners con- 

HRpt. 106-786 D-CO-2 



34 



tacted— usually 90% or more— voluntarily obtain an HIV test. But 
only 10 percent or less of people who have recently tested HIV-posi- 
tive manage, by themselves, to notify their partners. 

Partner notification is especially important for women because 
many HIV-infected women do not engage in high risk behaviors but 
were infected by a partner who does. Recent studies indicate that 
AIDS develops more quickly in women who would therefore benefit 
from being alerted to their condition as early as possible. Partner 
notification has been credited, in part, by the public health commu- 
nity for the fact that syphilis cases in the U.S. have fallen to the 
lowest levels in history. 

The Committee heard testimony from the State of Florida, which 
recently enacted a partner notification program, that such "activi- 
ties are effective interventions for reaching individuals at high risk 
of HIV infection and are unaware of their risk." States have been 
successful in reducing the number of new HIV infections— contrary 
to national trends— in large part to effective partner notification 
programs. 

The legislation authorizes $30 million for states to enact such 
policies, but does not require that they do so as a condition of eligi- 
bility for Title II funding. States with systems that are approved 
by the CDC will receive preference for these grants. No State that 
does not meet the CDC surveillance recommendations will be eligi- 
ble for these funds after 2004. 

Vulnerable Populations. The Committee is concerned that not all 
Americans receive the same quality of treatment under the CARE 
Act. As the GAO found in its report entitled "HIV/AIDS: Use of 
Ryan White CARE Act and Other Assistance Grant Funds": 

Women also did not fare as well as men on most of the 
measures. Finally, exposure category was a significant fac- 
tor; those who had acquired their infection by injecting 
drugs or through heterosexual sex had less favorable pat- 
terns of care than did men who had sex with men [MSM]. 

Therefore, the Committee strongly encourages the Office of HIV/ 
AIDS Policy and the Office on Women's Health (OWH) to provide 
a report to Congress on all activities conducted by the US Depart- 
ment of Health and Human Services that impact women who are 
infected and affected by HIV/AIDS. The report shall include an 
evaluation by the OWH of the scope and effectiveness of these ac- 
tivities. It will also identify gaps in prevention and care services 
and in research involving or targeted towards women living with 
HIV/AIDS. The HHS Secretary shall direct the appropriate agen- 
cies within the Department to collaborate with the OWH on such 
a report. 

Priority for Women, Infants, Children and Youth. The Committee 
has expanded the existing priority on services for women, infants 
and children to also include youth. The Committee intends the 
term "youth" to include persons between the ages of 13 and 24, and 
the term "children" to include those under the age of 13, including 
infants. 

The Committee emphasizes that the minimum amount estab- 
lished by H.R. 4807 is in no way to be construed as a maximum 
on how much a planning council may spend on these populations. 
The Committee also recognizes that these priority populations 



35 



often comprise a greater proportion of HIV cases rather than AIDS 
cases in a local area. If data on HIV, rather than the endstage of 
AIDS, are available, planning councils should take this into ac- 
count when allocating resources. 

The Committee recognizes that, according to the CDC, young 
people ages 24 and under account for at least half of new HIV in- 
fections. The Committee urges planning councils to assure that 
more is done to provide appropriate services to youth, including 
prevention, in coordination with Title IV grantees operating in the 
area. 

Perinatal Transmission. Perinatal transmission of HIV is the 
leading cause of pediatric cases AIDS, and the Committee recog- 
nizes the importance of life-saving newborn screening programs. 
According to the 1998 Institute of Medicine report "Reducing the 
Odds: Public Health Screening Programs", these programs have a 
long pedigree in the public health profession: 

The first parental screening program mandated by law 
was for syphilis in the 1930s and 1940s. In early 1960s, 
many states mandated newborn screening for PKU, a con- 
dition that can lead to mental retardation without dietary 
interventions, and other inborn errors of metabolism. 
Screening for other inborn errors of metabolism (congenital 
hypothyroidism, galactosemia, homocystinuria, 

histidenemia, maple syrup urine disease, and tyrosinemia) 
followed in the 1970s. In the early 1970s, many states ini- 
tiated mandatory screening for sickle cell disease, a dis- 
ease that had limited treatment options, in a variety of 
populations. Later in the same decade, maternal serum 
alpha-fetoprotein tests were introduced, on a voluntary 
basis, to help detect neural tube defects. Today, specific 
tests mandated or recommended as standards of practice 
vary substantially across state lines. Mandatory prenatal 
and newborn testing for substance abuse is increasingly 
common. 

Despite improved progress in developing effective strategies to 
reduce perinatal HIV transmission, the CDC estimates that nearly 
7,000 HIV-infected women give birth in the United States each 
year and as many as 400 babies continue to be born with HIV in- 
fection each year. Breastfeeding by HIV-infected mothers poses ad- 
ditional significant risk of infection to babies. 

Even if there were no effective therapies for perinatal HIV trans- 
mission, routine testing still would benefit the public health. As the 
1998 IOM report pointed out, 

In 1936, Thomas Parran, the U.S. Surgeon General, es- 
tablished a program for controlling syphilis that included 
mandatory prenatal blood tests * * *. Although these laws 
were passed before the introduction of antibiotic treat- 
ment, they resulted in rapid decline in congenital trans- 
mission through case finding * * * contact tracing, and 
the difficult and less effective therapies available at the 
time. Perhaps the most important aspect of these screen- 
ing programs was that by making testing routine, they 
overcame the resistance of physicians to risk offending pa- 
tients by suggesting a test for syphilis. 



36 



Fortunately, medical advances have made it possible to nearly 
eliminate perinatal HIV transmission. In 1994, research studies 
demonstrated that the administration of antiretroviral medication 
during pregnancy, during labor, and to the infant immediately fol- 
lowing birth can significantly reduce the transmission of HIV from 
an infected mother to her baby. From 1994 to 1999, as a result of 
these interventions, pediatric AIDS cases resulting from perinatal 
HIV transmission declined by nearly 80 percent. Subsequent stud- 
ies have indicated that cesarean sections further reduce the risk of 
transmission. Studies also indicate that, even if treatment begins 
shortly after birth, antiretroviral therapy can substantially reduce 
the chance that an HIV-exposed child will become infected. 

Due to the availability of interventions to reduce perinatal HIV 
transmission and to improve the health of HIV-infected women and 
their children, it is important to increase the number of pregnant 
women who receive prenatal care and are tested for HIV. In 1995, 
the House approved a measure requiring universal HIV testing of 
all newborns. The American Medical Association recommends HIV 
testing for all pregnant women and newborns with counseling and 
recommendations for appropriate treatment. The IOM has rec- 
ommended the adoption of a national policy of universal HIV test- 
ing, with patient notification, as a routine component of prenatal 
care. Regrettably, according to the IOM, 15 percent of HIV-infected 
pregnant women receive no prenatal care at all. 

The routine offering of HIV testing to pregnant women should be 
a standard of care. Sufficient information must be provided to a 
pregnant woman so she can make an informed decision to be test- 
ed. Studies show that the vast majority of pregnant women will ac- 
cept an HIV test if it is offered to them. In addition, testing 
newborns whose mothers' HIV status is unknown helps to ensure 
that children at risk for HIV are identified and provided treatment. 

The offering of HIV testing to pregnant women and to newborns 
whose mothers' HIV status is unknown, combined with appropriate 
counseling and treatment, can significantly reduce perinatal HIV 
transmission, improve access to medical care for HIV-infected 
women and children, and provide opportunities to farther reduce 
HIV transmission among adults. 

For the reasons cited above, the Committee finds the following: 
(1) universal, routine offering of HIV testing to pregnant women 
should be a standard of care; (2) HIV testing of newborns whose 
mothers' HIV status is unknown a standard of care; and (3) rel- 
evant medical organizations, public and private payers of health in- 
surance, and public health officials should issue or update relevant 
HIV counseling, testing and treatment guidelines accordingly. 

The Committee also recognizes the need for additional resources 
to further reduce perinatal HIV transmission. The legislation au- 
thorizes an additional $20 million for activities to reduce perinatal 
transmission, including outreach, education, testing and treatment 
for pregnant women and their newborns. 

The current statute requires, as a condition of funding, that 
States have regulations or measures to adopt CDC guidelines con- 
cerning HIV counseling and testing for pregnant women and 
newborns. Women who initially refuse testing should be encour- 
aged to reconsider at later points in their pregnancy. When appro- 
priate, pregnant women who accept testing when it is initially of- 



37 



fered and test negative should be encouraged to get tested again 
later in pregnancy. 

Additionally, consistent with State laws and regulations, suffi- 
cient information should be provided to all pregnant women so they 
can make an informed decision to be tested for HIV. Adequate 
training and education should be provided to prenatal care pro- 
viders on the risks of perinatal transmission, and the importance 
of offering HIV tests to all pregnant women, the benefits of inter- 
ventions, and the availability of referral sites for women who test 
positive should be emphasized. 

The Committee also believes that it is also important that appro- 
priate post-test counseling, referrals, and linkages to care for HIV- 
positive women and their children be provided, and that women are 
not counseled to terminate their pregnancies on the basis of HIV 
status. States should also have to show that they are taking steps 
to increase the proportion of women who receive prenatal care, in- 
cluding targeted outreach and education efforts in areas with high- 
est numbers of women who get no or inadequate prenatal care. Re- 
forms to State insurance laws should require that, if health insur- 
ance is in effect for an individual, the insurer involved may not 
(without the consent of the individual) discontinue the insurance, 
or alter the terms of the insurance, solely on the basis that an indi- 
vidual has been tested for HIV or is infected with HIV. 

The Committee has reserved a portion of the additional funding 
for States that conduct HIV testing of all newborns, or newborns 
whose mothers' HIV status is unknown. If newborn testing is con- 
ducted, in order to maximize the opportunity for reduction of 
perinatal transmission after birth, the Committee urges states to 
assure that test results are provided within 48 hours. The Com- 
mittee recognizes that HIV test results for the newborn will gen- 
erally also reveal the HIV status of the mother. Therefore, if a new- 
born tests positive for HIV, it is essential for the mother to be in- 
formed of the test results and provided care in a sensitive manner 
that is consistent not only with CDC guidelines, but also with ap- 
propriate measures to protect the confidentiality of both mother 
and child. 

The Committee encourages all states, including those that do not 
apply for this additional funding, to take these steps and other ac- 
tivities as necessary to reduce perinatal HIV transmission. States 
are encouraged to coordinate their activities with those of Title IV 
grantees and other entities that provide services related to the re- 
duction of perinatal HIV transmission. Where appropriate, states 
are encouraged to provide a portion of grants under this section to 
Title IV grantees operating in the State. 

To assure that there are no financial barriers to the offering of 
HIV testing to all pregnant women or to providing treatment to re- 
duce perinatal HIV transmission and improve the health of HIV- 
positive women and children, the Committee encourages all payers 
of health insurance, both public and private, to assure that HIV 
testing and treatment during pregnancy and for the mother and 
child are covered benefits. 

The Committee requires that States report to Congress on the 
progress toward meeting the recommendations of the IOM. Those 
who have not made progress toward meeting such recommenda- 
tions must, as a condition of receiving funding, cooperate with the 



38 



CDC and submit a report to the Secretary on progress identifying 
and overcoming barriers to eliminating perinatal HIV trans- 
mission. 

The Committee does not intend that this bill detrimentally affect 
religious practices or religious freedom. However, nothing in this 
bill is designed to preempt existing or prohibit new State religious 
accommodation laws that allow those with religious objections to 
decline to have their newborn infants tested for HIV disease if such 
exemptions exist under state law for other reportable diseases. Fur- 
ther, religious accommodation laws enacted by recipient States 
shall have no impact whatsoever on the level of federal funding re- 
ceived by the recipient State. 

The Committee heard testimony from Mr. Tom Liberti, Chief, 
Bureau of HIV/AIDS, Florida Department of Health, who detailed 
how the enactment of a successful HIV reporting system enabled 
the state to better address the epidemic, particularly within the Af- 
rican-American and Hispanic communities. The availability of such 
a system will better ensure that all communities affected are recog- 
nized and are receiving appropriate care and medical access, there- 
by reducing disparities and allowing for the equitable allocation of 
funds. 

Minority AIDS Initiative. While the Ryan White CARE Act, in 
general, has had significant success in addressing the needs of indi- 
viduals and communities affected by the disease, ethnic and racial 
minority communities continue to experience disparities in health 
outcomes in terms of HIV and AIDS. The legislation includes sev- 
eral provisions that intend to refocus and enhance representation, 
planning, prioritization, and allocation of CARE Act resources to 
address disparities in health outcomes and the needs of historically 
underserved and vulnerable communities. 

According to the written testimony of Loretta Davis-Satterla, Di- 
rector, Division of HIV/AIDS-STD with the Michigan Department 
of Community Health submitted for the Subcommittee on Health 
and Environment hearing on May 11, 2000: 

In Michigan, confidential HIV reporting has been re- 
quired by statute since 1989. Confidential HIV reporting 
has greatly enhanced Michigan's ability to rapidly and ef- 
fectively respond to the dynamics of this epidemic * * * In 
contrast to AIDS case surveillance, HIV case surveillance 
provides data to better characterize populations in which 
HIV infection has been newly diagnosed, including persons 
with evidence of recent HIV infection. Compared with per- 
sons living with AIDS, those reported living with HIV in- 
fection in Michigan are more likely to be women (18% for 
AIDS vs 26% for HIV) and African Americans (55% for 
AIDS and 62% for HIV). Approximately 1% of AIDS cases 
occurred in both persons aged 13-19 years and 20-24 
years. In comparison, 4% of HIV cases occurred in persons 
aged 13-19 years and 13% of HIV cases occurred in per- 
sons 20-24 years. Thus, AIDS case surveillance alone does 
not accurately reflect the extent of the HIV epidemic 
among African Americans, women, adolescents and young 
adults. 



39 



In addition, the Committee affirms the intent of the Minority 
AIDS Initiative (MAI) in addressing the unique needs of ethnic and 
racial minority communities. The initiative is intended to com- 
plement and supplement, not supplant, the efforts of the Ryan 
White CARE Act and other national AIDS programs. The MAI was 
instituted in response to the overwhelming and disproportionate 
impact of the HIV epidemic on ethnic and racial minority commu- 
nities. 

The MAI is intended to address the needs of Americans in highly 
impacted communities by enhancing outreach and education, 
strengthening technical assistance, and supporting capacity build- 
ing of ethnic and racial minority community based organizations 
and institutions and providers to deliver culturally competent and 
appropriate HIV-related prevention, health care, and support serv- 
ices. The initiative also seeks to expand or fund new research ini- 
tiatives to develop and evaluate culturally competent intervention 
strategies directed towards reducing and ultimately eliminating the 
HIV-related health disparities experienced by ethnic and racial mi- 
nority populations. In this regard, the MAI may prove to be a sig- 
nificant component of an overall strategy for addressing the dis- 
ease. The Committee encourages the Department of Health and 
Human Services to include the MAI in its efforts to achieve an in- 
tegrated and coordinated system of HIV/AIDS care and treatment. 
With respect to entities that currently receive or have received 
planning grants through special initiatives such as the MAI, the 
Committee intends that these entities will be still be eligible for 
such grants under Part C if they meet the appropriate funding cri- 
teria. 

MAI funding is intended to be targeted to ethnic and racial mi- 
nority-governed and staffed organizations and where no such orga- 
nization exist, to institutions that have a history of providing cul- 
turally competent services to the communities and populations they 
are targeting. The funding is intended to build capacity and infra- 
structure within these communities, and fill gaps in critically need- 
ed HIV and AIDS services. This includes providing primary HIV 
prevention, increasing access to HIV and related health and sup- 
port services, and ensuring continuity of care for ethnic and racial 
minority populations and sub-populations including minority 
women, youth, MSMs, substance abusers, homeless, incarcerated 
and recently-released in divi duals. 

Incarcerated Populations. The Committee recognizes that HIV 
public health interventions implemented in correctional settings 
have great potential to have a significant impact on the epidemic. 
The success of in-prison interventions requires continuation of med- 
ical treatment and behavior modification following release. Post-re- 
lease failure of inmates to adhere to HIV medical regimens may 
pose public health dangers by fostering development and trans- 
mission of drug-resistant HIV variants. Also, because the vast ma- 
jority of inmates will be released to their communities, prison, jail, 
and similar restricted institutions intervention is vital to reduce 
HIV transmission to the general public. Therefore, the Committee 
believes that improved discharge planning and continuity of care 
between correctional facilities and communities are needed to in- 
crease the likelihood that HIV-positive releasees will obtain the 
care they need and take precautions to avoid spreading the disease. 



40 



Effective pre-release programs can also help inmates make positive 
changes in their lives to avoid returning to crime, with the result- 
ing reduced recidivism rates yielding significant benefits to society. 
The Committee therefore urges the Secretary to give favorable con- 
sideration to grants under the Ryan White CARE Act for programs 
that provide linkages with correctional discharge planning and 
other transitional services needed to help HIV-positive inmates 
move successfully from correctional institutions to their commu- 
nities. These transitional services, which may be needed up to six 
months prior to release, may include, but are not limited to, clinical 
referrals, psychosocial services, enrollment in medical care funding 
programs, a short-term supply of medications upon release, HIV 
pre-release identification efforts, HIV prevention education, HIV 
related counseling, coordination and referral, and linkages for sub- 
stance abuse treatment, and HIV related case management serv- 
ices and linkages to CARE Act programs in their communities. 

In addition to prisons and jails, other residential institutions, 
such as substance abuse treatment facilities and mental health in- 
stitutions, also have a high concentration of persons at high risk 
of HIV infection and pose similar intervention opportunities and 
challenges. The Committee thus urges the Secretary to give favor- 
able consideration to grants under the Ryan White CARE Act for 
programs that provide discharge planning and other transitional 
services, including the types of services enumerated above, which 
are needed to help HIV-positive institutional residents move suc- 
cessfully from institutions to their communities. 

Quality Assurance. The Committee recognizes the importance of 
having CARE Act grantees ensure that quality services are pro- 
vided to people living with HIV and that the quality management 
activities are conducted on an ongoing basis. Quality management 
activities should: assess the extent to which HIV health services 
provided under this grant are consistent with Public Health Service 
guidelines for the treatment of HIV and the treatment and preven- 
tion of related opportunistic infections and, as applicable, lead to 
the development of strategies to ensure that such services are con- 
sistent with the guidelines and that social support services are pro- 
vided in a manner as to gain or enhance the benefits of health care 
services. 

The Committee expects the Secretary to provide States with 
guidance and technical assistance for establishing quality manage- 
ment programs, including disseminating such models that have 
been developed by States and are already being utilized by Title II 
programs and in clinical practice environments. The Committee 
hopes that States will communicate and coordinate CARE Act re- 
quirements with other payers to the extent possible to ensure con- 
sistency in quality management activities. The Committee expects 
that most States have quality management systems in place al- 
ready and that they utilize mechanisms such as peer chart reviews 
or patient prescription pattern monitoring. The Committee places 
responsibility on the Secretary to ensure that PHS guidelines, as 
well as population characteristics and trends in the use of HIV 
services, are communicated to all CARE Act grantees and sub- 
grantees. This information, the Committee believes, will assist 
grantees in ensuring the highest quality of HIV care among CARE 
Act providers. 



41 



The Committee intends that the Secretary provide clarification 
and guidance regarding the distinction between use of CARE Act 
funds for such program expenditures that are covered as either 
planning and evaluation and funds for program support costs. Pro- 
gram support costs are described as any expenditure related to the 
provision of delivering or receiving health services supported by 
CARE Act funds. As applied to the clinical quality programs, these 
costs include, but are not limited to, activities such as chart review, 
peer-to-peer review activities, data collection to measure health in- 
dicators or outcomes, or other types of activities related to the de- 
velopment or implementation of a clinical quality improvement pro- 
gram. Planning and evaluation costs are related to the collection 
and analysis of system and process indicators for purposes of deter- 
mining the impact and effectiveness of funded health-related sup- 
port services in providing access to and support of individuals and 
communities within the health delivery system. 

HIV Consortia. The Committee intends that States continue to 
work with local Consortia to ensure that they identify potential dis- 
parities in access to HIV care services at the local level, with a spe- 
cial emphasis on those experiencing disparities in access to care, 
historically underserved populations, and HIV infected persons not 
in care. However, the Committee does not intend that States and/ 
or Consortia be mandated to consult with all entities referenced as 
part of the planning process under Part A. The Committee intends 
that States and Consortia will continue to work with the appro- 
priate entities in their jurisdictions to assess and plan services at 
the local level. Reference to entities included in the Title I planning 
process is intended to provide guidance to the States that such en- 
tities are important constituencies which the States should endeav- 
or to include in their planning processes. The Committee intends 
that the States require local Consortia to document their efforts to 
identify and address access disparities at the local level, as appro- 
priate. 

Title II Comprehensive Plan. The comprehensive service delivery 
plan is an effective way to demonstrate the organization and deliv- 
ery of CARE Act services, based upon the planning, priority set- 
ting, and funding allocations processes conducted by the State. The 
Committee intends that States may demonstrate compliance with 
the new requirement of an enhanced process of public participation 
by indicating in their applications existing mechanisms for con- 
sumer and community input, and describing how such mechanisms 
influence the use and distribution of funds and the number of per- 
sons not in care and unmet needs of persons not receiving health 
services. The Committee intends States to develop a strategy to 
identify individuals with HIV disease who are not receiving serv- 
ices and to inform and enable such individuals to receive services 
under Title II. The Committee wants CARE Act providers to work 
actively to bring into and retain in care those individuals who are 
unaware of their HIV status and those who are knowledgeable of 
their status but are not receiving services. As part of this process, 
the Committee believes strongly in the importance of the States fo- 
cusing on eliminating disparities in access and services among af- 
fected subpopulations and historically underserved communities. 
The Committee recognizes that the availability or lack of HIV prev- 
alence data in particular States will be reflected in the scope, goals, 



42 



timetable and allocation of funds for implementation of the strat- 
egy. 

The Committee also intends States to develop a strategy to co- 
ordinate the provision of Title II services with HIV prevention serv- 
ices and substance abuse prevention and treatment services. The 
Committee has amended numerous aspects of CARE Act programs 
to enhance the coordination between HIV prevention and HIV care 
and treatment services. 

The Committee intends that additional factors be reflected in the 
plan such as disparities in access to medical and health-related 
support services by subpopulations. Upon the development of meas- 
ures by the Secretary and Title II grantees, as described above, the 
needs of persons with HIV not in care should be considered in the 
comprehensive plan. Both the planning process and the resulting 
plan should continue to include the participation of, and address 
the needs of, populations and subpopulations living with HIV and 
AIDS. The specific needs of populations or subgroups, such as 
women, people of color, persons who are underinsured or unin- 
sured, youth, homeless persons, persons living in rural areas, or 
persons with substance abuse or other co-occurring conditions with- 
in the State need to be specifically addressed. States should con- 
tinue to consider the availability of services through other public 
and private health care payers and providers including Medicaid, 
the State Children's Health Insurance Program (SCHIP) and other 
public and private sources of health care reimbursement. States 
should ensure that there are strong coordinating mechanisms be- 
tween Ryan White and the State Medicaid programs to assure opti- 
mal health care for persons living with HIV disease. States should 
continue to collaborate with other health care and social service 
providers and payers through the Statewide Coordinated State- 
ment of Need (SCSN) process. The Committee does not intend to 
mandate that States devote specific portions of their Title II grant 
funds to specific activities. The Committee recognizes the need for 
flexibility for States in the administration of Title II programs in 
order to ensure that local needs are addressed. 

ADAP. The legislation strengthens the ADAP program to assist 
States that are struggling to provide medications to all of their 
needy clients. The Committee has also sought to strengthen the 
ability of local communities, States, and service organizations to 
reach those communities and populations that have been histori- 
cally most underserved, as well as those that are experiencing 
rapid increases in HIV infection and AIDS case counts but that 
have not been brought into the care system developed under Ryan 
White. The purpose of these changes is to ensure a strong system 
of health care delivery and access to therapies commensurate with 
evolving needs. 

This section has been amended to permit States to utilize funds 
under this section to purchase and maintain health insurance on 
behalf of individuals with HIV disease whose coverage provides a 
full range of HIV therapeutics and primary care services. The Com- 
mittee recognizes the cost-effectiveness and potential cost-savings 
of such a mechanism in the provision of treatments and the fact 
that several States have already fully integrated such mechanisms 
into their treatment provision systems. 



43 



Grants for Coordinated Services and Access to Research for 
Women, Infants, Children and Youth. The Committee does not in- 
tend to require Title IV applicants to file separate reports to the 
Secretary to demonstrate linkages to research and how access to 
such research is offered to patients. Instead, such reporting may be 
completed as part of the existing grantee reporting process. The re- 
port on the distribution and availability of ongoing and appropriate 
HIV/AIDS-related research projects shall not be interpreted as re- 
quiring the Secretary to recommend the redistribution of funds for 
such research projects or to act on redistributing these funds based 
on the report's findings. 

Early Intervention Services. The Committee expects that EMAs 
will provide services to American Indian and Native American peo- 
ples. Native Americans and American Indians are eligible for Ryan 
White services through State and Federal citizenship. The Com- 
mittee supports better co-ordination of Ryan White services for Na- 
tive Americans and American Indians in order that they may real- 
ize the full potential of HIV/AIDS-related primary care and support 
services provided through CARE Act funding. 

The Committee also recognizes that the US Department of Vet- 
erans Affairs is the largest single direct provider of HIV care and 
services in the US. Over 18,000 veterans received HIV care at VA 
facilities in 1999. Veterans with HIV infection are eligible to par- 
ticipate in Ryan White Title I programs when they meet eligibility 
requirements set by Title I Planning Councils, and EMA plans for 
the delivery of services must account for the availability of VA 
services. VA facilities are eligible providers of HIV health and sup- 
port services where appropriate. The Committee expects that 
HRSA's Bureau of HIV/AIDS shall encourage Ryan White grantees 
to develop collaborations between providers and VA facilities to op- 
timize coordination and access to care to all persons in Title I 
EMAs. 

The Committee understands that the Secretary has convened a 
Public Health Service Working Group on HIV Treatment Informa- 
tion Dissemination, which has produced recommendations and a 
strategy for the dissemination of HIV treatment information to 
health care providers and patients. Recognizing the importance of 
such a strategy, the Committee intends that the Secretary issue 
and begin implementation of the strategy to improve the quality of 
care received by people living with HIV/AIDS. 

Administrative Simplification. The Committee is aware of the 
enormous administrative burden that the current grant application 
process places on States and recipients of grants under Part A. The 
Committee is concerned that the current application process may 
divert critical resources from the provision of care. Therefore, the 
Committee directs the Secretary to consult with States and recipi- 
ents of grants under Part A regarding the coordinated disburse- 
ment of funds under Part A with the disbursement of funds under 
Part B, the implementation of a biennial application process under 
Parts A and B, and the overall simplification and streamlining of 
the grant application for funds under Parts A and B. The Com- 
mittee expects that the Secretary will undertake this consultation 
with States and entities receiving funds under Part A in an expedi- 
tious manner and will work with these States and entities to im- 
plement agreed upon strategies as soon as possible. 



44 



Audits and Consumer Participation. The Committee intends that 
to the maximum extent possible the funds made available through 
this legislation are intended for the actual medical and support 
services needs of the infected population, and not simply "quality 
of life" issues. According to a November 13, 1997 New York Times 
story, some services that have been offered using Federal funds in- 
cluded "free dog walking." Any funds misallocated through frivolity, 
waste or outright fraud deny someone else living with HIV much 
needed care. 

At the July 11, 2000 hearing the Subcommittee heard testimony 
from Jose Fernando Colon, Coordinator for Pacientes de SIDA Pro 
Politica Sana (AIDS Patients for Sane Policies) in San Juan, Puerto 
Rico. Mr. Colon detailed for the Committee how millions of dollars 
of money intended for AIDS services was diverted for personal and 
political purposes, resulting in numerous Federal Court convictions 
in Puerto Rico. He testified that in 1993 the Department of Health 
and Human Services was made aware of possible misconduct, but 
that no investigation was ever conducted. 

The GAO reported to the Congress on October 18, 1999 that they 
had identified two other cases in which fraud and abuse have oc- 
curred in regard to CARE Act funds. However, the GAO did not 
find such fraud and abuse to be either systemic or widespread 
among grantees or in CARE Act programs. As HRSA Administrator 
Claude Fox, MD testified to the Subcommittee: 

The GAO has looked at it and said there is not a wide- 
spread problem. We agree with the provisions in this bill. 
We want to do everything that we can do within reason to 
make sure that these funds are well spent. But we do not 
believe that it is a widespread problem. 

H.R. 4807 includes important provisions to prevent and detect 
fraud with CARE Act funds. 

The legislation also contains important provisions which ensure 
that not less than 33% of Title I HIV Health Services Planning 
Councils are composed of individuals who are receiving HIV-related 
services. 

The Committee emphasizes that its intent is to ensure that pa- 
tients and consumers of Title I services constitute a substantial 
proportion of Planning Council memberships. The prohibition of of- 
ficers, employees and consultants is not intended to impede the 
participation of qualified, motivated volunteers with Title I grant- 
ees from serving on Planning Councils where they do not maintain 
significant financial relationships with such grantees. In contrast 
to such significant financial relationships, volunteers may be reim- 
bursed reasonable incidental costs, including for training and 
transportation, which help to facilitate their important contribution 
to the Planning Councils. 

The Committee intends that Planning Councils ensure its mem- 
bers are knowledgeable about their duties, the functions of the 
Councils, and the Councils' role in the organization and delivery of 
HIV/AIDS health and support services. The provision of training 
guidance and materials to the Councils by HRSA's Bureau of HIV/ 
AIDS will go far to ensure that Council members, particularly pa- 
tients and consumers of HIV/AIDS services, can serve effectively 



45 



and improve the allocation of resources and the planning and im- 
plementation of Title I services. 

The Committee also expects Planning Councils to provide assist- 
ance, such as transportation and childcare, to facilitate the partici- 
pation of consumers, particularly those from affected subpopula- 
tions and historically underserved communities. 

Further, the bill ensures that grants will be available for train- 
ing members of these planning councils, and that planning council 
meetings will be open to the public. Mr. Colon stated that these 
types of reforms will lead to increased accountability, and the Com- 
mittee agrees with this assessment. 

Further, for the first time, the Committee intends that the Sec- 
retary may reduce grants to States or political subdivisions of 
States which fail to prepare and submit audits to the Secretary. 
From these audits, the Secretary must annually randomly review 
samples of the audits, ensuring that CARE Act funds are being ap- 
propriately expended. 

Hearings 

The Subcommittee on Health and Environment held a hearing on 
July 11, 2000. The Subcommittee received testimony from: Claude 
Earl Fox, M.D., M.P.H., Administrator, Health Resources and Serv- 
ices Administration, accompanied by Joseph O'Neil, M.D., M.P.H., 
Associate Administrator, Bureau of HIV/AIDS, Health Resources 
and Services Administration; Ms. Janet Heinrich, Associate Direc- 
tor, US General Accounting Office, accompanied by Mr. Jerry 
Fastrup, Assistant Director, US General Accounting Office; Ms. 
Jeanne White, National Spokesperson, AIDS Action; Mr. Tom 
Liberti, Chief, Bureau of HIV/AIDS, Florida Department of Health; 
Guthrie S. Birkhead, M.D., M.P.H., Director, AIDS Institute, New 
York State Department of Health; Mr. Joe Davy, Policy Advocate, 
Columbus AIDS Task Force; Ms. Dorothy Mann, Board Member, 
AIDS Alliance for Children, Youth & Families; Mr. Jose F. Colon, 
Coordinator, Pacientes de SIDA Pro Politica Sana and; Mr. Eugene 
Jackson, Deputy Executive Director for Policy, National Association 
of People with AIDS. 

Committee Consideration 

On July 13, 2000, the Full Committee met in open markup ses- 
sion and ordered reported H.R. 4807, the Ryan White CARE Act 
Amendments of 2000, as amended, by a voice vote. 

Committee Votes 

Clause 3(b) of rule XIII of the Rules of the House of Representa- 
tives requires the Committee to list the record votes on the motion 
to report legislation and amendments thereto. There were no 
record votes taken in connection with ordering H.R. 4807 reported. 
A motion by Mr. Bliley to order H.R. 4807 reported to the House, 
with an amendment, was agreed to by a voice vote. 
The following amendments were agreed to by a voice vote: 

An amendment by Mr. Coburn, No. 1, making various tech- 
nical changes to the bill; and 

An amendment by Mr. Strickland, No. 4, ordering States, 
consortia, and supplemental grant applicants to seek comment 



46 



from an expanded body of stakeholders used by Title I EMA 
cities when preparing their required plans. 
The following amendments were withdrawn by unanimous con- 
sent: 

An amendment by Ms. Eshoo, No. 2, replacing the "hold 
harmless" provision in the bill with the Senate provision reduc- 
ing the cut in Title I funds to 2% per year over 5 years; and 

An amendment by Ms. DeGette, No. 3, giving States the op- 
tion to cover pregnant women under the State Children's 
Health Insurance Program. 

Committee Oversight Findings 

Pursuant to clause 3(c)(1) of rule XIII of the Rules of the House 
of Representatives, the Committee held legislative and oversight 
hearings and made findings that are reflected in this report. 

Committee on Government Reform Oversight Findings 

Pursuant to clause 3(c)(4) of rule XIII of the Rules of the House 
of Representatives, no oversight findings have been submitted to 
the Committee by the Committee on Government Reform. 

New Budget Authority, Entitlement Authority, and Tax 

Expenditures 

In compliance with clause 3(c)(2) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that H.R. 4807, the 
Ryan White CARE Act Amendments of 2000, would result in no 
new or increased budget authority, entitlement authority, or tax 
expenditures or revenues. 

Committee Cost Estimate 

The Committee adopts as its own the cost estimate prepared by 
the Director of the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974. 

Congressional Budget Office Estimate 

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 
of Representatives, the following is the cost estimate provided by 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974: 

U.S. Congress, 
Congressional Budget Office, 

Washington, DC, July 24, 2000. 

Hon. Tom Bliley, 

Chairman, Committee on Commerce, 
House of Representatives, Washington, DC. 

Dear Mr. Chairman: The Congressional Budget Office has pre- 
pared the enclosed cost estimate for H.R. 4807, the Ryan White 
CARE Act Amendments of 2000. 



47 



If you wish further details on this estimate, we will be pleased 
to provide them. The CBO staff contact is Julia Christensen. 
Sincerely, 

Steven Lieberman 
(For Dan L. Crippen, Director). 

Enclosure. 

H.R. 4807 -Ryan White Care Act Amendments of 2000 

Summary: H.R. 4807 would reauthorize programs in title XXVI 
of the Public Health Services Act, which was created by the Ryan 
White CARE Act (Public Law 101-381). Programs funded under 
the Ryan White CARE Act address the needs of individuals living 
with HIV disease. The bill would amend certain provisions under 
that title to increase access to care and require that care to be con- 
sistent with the guidelines of the Public Health Service (PHS). The 
bill also would create new grant programs to: 

• Pay for health care services for individuals with HIV dis- 
ease in states ineligible for emergency relief grants; 

• Establish partner notification programs in the states, and 

• Provide to states technical assistance with setting up data 
surveillance and reporting systems related to HIV disease and 
other funding for data collection efforts. 

The Health Resources and Services Administration (HRSA) 
under the Department of Health and Human Services (HHS) ad- 
ministers most of the Ryan White CARE Act programs; small por- 
tions are implemented through the Centers for Disease Control and 
Prevention (CDC) and the National Institutes of Health (NTH). As- 
suming the appropriation of the necessary amounts, CBO estimates 
that implementing H.R. 4807 would cost $351 million in 2001 and 
$6.7 billion over the 2001-2005 period, without adjusting for infla- 
tion. The five-year total would be $7 billion if adjustments for infla- 
tion are included. The legislation would not affect direct spending 
or receipts; therefore, pay-as-you-go procedures would not apply. 

H.R. 4807 contains no private-sector mandates as defined in the 
Unfunded Mandates Reform Act (UMRA). It does contain an inter- 
governmental mandate as defined in UMRA, but it also contains 
new budget authority' for grants that may be used by states to 
cover the costs associated with the mandate. Consequently, the 
threshold established in UMRA ($55 million in 2000, adjusted an- 
nually for inflation) would not be exceeded. 

Estimated cost to the Federal Government: The estimated budg- 
etary impact of H.R. 4807 is shown in Table 1. The costs of this 
legislation fall within budget function 550 (health). 

TABLE 1.— BUDGETARY IMPACT OF H.R. 4807 



By fiscal year, in millions of dollars — 
2000 2001 2002 2003 2004 2005 



SPENDING SUBJECT TO APPROPRIATION 

_ 1.605 0 0 0 0 0 

„ 1,376 1,209 248 64 P) 0 

Without Adjustment for Inflation 
Proposed Changes-. 

Estimated Authorization Level 0 1,711 1,711 1,711 1.711 1.711 



Spending Under Current Law: 

Budget Authority 1 

Estimated Outlays 



48 

TABLE 1.— BUDGETARY IMPACT OF H.R. 4807— Continued 



By fiscal year, in millions of dollars — 





2000 


2001 


2002 


2003 


2004 


2005 


Estimated Outlays 


0 


351 


1,402 


1,608 


1,676 


1,678 


Spending Under H.R. 4807 














Estimated Authorization Level 1 


1,605 


1,711 


1,711 


1,711 


1,711 


1,711 


Estimated Outlays 


, 1,376 

With Adjustments for Inflation 


1,559 


1,650 


1,672 


1,676 


1,678 


Proposed Changes: 














Estimated Authorization Level 


0 


1,793 


1,766 


1,800 


1,834 


1,866 


Estimated Outlays 


0 


356 


1,431 


1,663 


1,764 


1,798 


Spending Under H.R. 4807: 














Estimated Authorization Level 1 


1,605 


1,739 


1,766 


1,800 


1,834 


1,866 


Estimated Outlays 


1,376 


1,565 


1,679 


1,728 


1,764 


1,798 



'The 2000 level is the amount appropriated for that year for title XXVI programs. 
2 Less than $500,000. 



Basis of estimate: For this estimate, CBO assumes that the bill 
will be enacted by the end of fiscal year 2000 and that outlays will 
follow historical spending rates for the authorized activities. Where 
specified in H.R. 4807, CBO assumes the authorized amounts 
would be appropriated. Where appropriations of such sums as nec- 
essary are authorized, CBO based its estimates on amounts spent 
in the past for similar types of activities. Table 1 shows two alter- 
native spending paths: one assuming no increase to account for in- 
flation, and one with annual inflation adjustments. 

Reauthorization of existing programs 

The authorizations for appropriations for most of the programs 
under the Ryan White CARE Act expire at the end of fiscal year 
2000. H.R. 4807 would reauthorize those programs for fiscal years 
2001 through 2005. Table 2 shows the amount appropriated in fis- 
cal year 2000, and the estimated authorization levels under H.R. 
4807 for fiscal years 2001 through 2005, with adjustments for infla- 
tion. 

TABLE 2.— TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS 
AUTHORIZED IN H.R. 4807, WITH ADJUSTMENTS FOR INFLATION 



By fiscal year, in millions of dollars— 





2000 


2001 


2002 


2003 


2004 


2005 


Programs Administered by HRSA 












Reauthorizations: 1 














Part A (Title 1 of the Ryan White CARE Act) emergency relief 














grants 


547 


556 


566 


576 


586 


597 


Part B (Title II) HIV care grants 


824 


839 


853 


868 


884 


900 


Part C (Title III) early intervention services 


138 


141 


143 


146 


149 


151 


Part D (Title IV) pediatric AIDS: women, children, and youth 


51 


52 


53 


54 


55 


56 


Part D (Title IV) evaluations and reports 


0 


4 


4 


4 


4 


4 


Part F demonstration and training AIDS education and training 














centers 


27 


27 


28 


28 


29 


29 


Dental reimbursements 


8 


8 


8 


8 


9 


9 


Modifications to Current Programs: 














Planning and capacity development grants 


0 


6 


6 


6 


6 


6 


AIDS education and training centers 


0 


15 


17 


20 


20 


21 


Other activities 


0 


6 


1 


1 


1 


1 


New programs: 














Supplemental grants for certain states ineligible for Part A 














grants 


0 


0 


0 


0 


3 


3 



49 



TABLE 2.— TITLE XXVI PROGRAMS: APPROPRIATIONS FOR FISCAL YEAR 2000 AND AMOUNTS 
AUTHORIZED IN H.R. 4807, WITH ADJUSTMENTS FOR INFLATION— Continued 



By fiscal year, in millions of dollars— 
2000 2001 2002 2003 2004 2005 
Complaint partner notification program 0 30 31 31 32 32 

Subtotal 1,595 1,683 1,709 1,743 1,777 1,808 

Programs Administered by CDC 

HIV-related services for pregnant women and newborns 1 10 30 30 30 30 30 

Data collection, reports, and other activities 0 25 26 26 26 27 

Provisions Administered by NIH 
Expansion of HIV research funds for affordable HIV testing and 
issuance of reports 0 1 1 1 1 1 

Total Proposed Changes 1,605 1,739 1,766 1,800 1,834 1,866 

1 The 2000 level is the amount appropriated for that year. 

HRSA Programs. The bill would reauthorize several programs or- 
ganized under different parts of the Ryan White Care Act: 

• Part A of title XXVI, (also known as title I of the Ryan White 
CARE Act), is the Emergency Relief Grant program. It provides 
grants to eligible metropolitan areas (EMAs) severely affected by 
the HIV epidemic. The funds are used for outpatient and ambula- 
tory health care and other support services provided by community- 
based systems to low-income or under-insured people living with 
HIV/AIDS. 

• Part B, (title II of the act), is the HIV Care Grant program. 
It provides grants to states and territories for health care and so- 
cial support services. Services are delivered primarily through con- 
sortia of providers of HIV services. Some Part B funds also are ear- 
marked to pay for drug treatment for certain individuals with HIV 
disease. In addition, states may use grant money to help low-in- 
come individuals purchase health insurance through Health Insur- 
ance Continuation programs. 

• Part C, (title III of the act), is the Early Intervention Services 
program. It awards grants to public and private nonprofit commu- 
nity-based programs that provide comprehensive primary health 
care services targeting at-risk populations and aim to reduce or 
prevent HIV-related morbidity. 

• Part D, (title IV of the act), contains general provisions. The 
pediatric AIDS: women, children, and youth program provides 
funding to improve and expand the primary care and support serv- 
ices for special populations living with HIV disease. The program 
aims to increase access to comprehensive, coordinated, community- 
based family-centered systems of care for infected individuals and 
their families. 

• Part F 1 contains the demonstration and training programs. It 
authorizes a network of regional centers that conduct HIV/AIDS 
education and training programs for healthcare providers, special 
projects of national significance relating to the development of in- 
novative models of HIV/AIDS care, and financial assistance to den- 



1 There has never been an appropriation for Part E, which requires the Secretary to make 
grants to state and local governments to assist them in disseminating guidelines to emergency 
responses employees regarding reducing the risk in the workplace of becoming infected with 
AIDS. 



50 



tal schools for uncompensated oral health care costs for patients 
with HIV disease. 

CBO estimates that reauthorizing those provisions would cost 
$325 million in 2001 and $6.6 billion over the 2001-2005 period. 

CDC Programs. H.R. 4807 would authorize a CDC-administered 
program that provides HIV-related services to pregnant women and 
newborns. The bill would authorize the appropriation of $30 million 
a year and would expand the services covered under the program. 
If at least $10 million is appropriated, part of the amount above 
$10 million would be set aside for states that comply with certain 
requirements such as mandatory testing. CBO estimates that this 
provision would cost $11 million in 2001 and $122 million over the 
2001-2005 period. 

Modifications to current programs 

The bill would make several modifications to existing programs. 
Those changes and their estimated budgetary effects are described 
below. In total, CBO estimates that implementing these modifica- 
tions would cost $5 million in 2001 and $102 million over the 
2001-2005 period. 

Planning and Capacity Development Grants. Section 312 of H.R. 
4807 would authorize a program of capacity development grants to 
assist public and nonprofit private entities in expanding their abil- 
ity to provide primary care and early intervention services to indi- 
viduals with HIV disease in underserved communities. Under cur- 
rent law, a maximum of 1 percent of the amount appropriated for 
Part C can be used for planning grants. H.R. 4807 would increase 
to 5 percent the proportion that could be earmarked for the new 
capacity development grants and the planning grants. The max- 
imum new capacity development grant would be set at $150,000 
under the bill. CBO estimates this provision would cost $1 million 
in 2001 and $23 million through 2005. 

AIDS Education and Training Centers and Dental Reimburse- 
ments. H.R. 4807 would allow the Secretary of HHS to fund 
projects to develop and disseminate treatment guidelines and pro- 
tocols for prenatal and gynecological care of women with HIV dis- 
ease. It also would authorize training of health professionals in 
that area. H.R. 4807 would require the Secretary to develop and 
implement a strategy for disseminating HIV-related information to 
health care providers and patients. The bill also would modify the 
dental school grant program to allow partnership agreements be- 
tween dental programs and community-based dentists to provide 
services in unserved areas. Finally, the bill would permit certified 
dental hygiene programs to receive reimbursement for uncompen- 
sated oral health care services provided to individuals with HIV 
disease under the dental reimbursement program. CBO estimates 
that those provisions would cost $3 million in 2001 and $71 million 
over the 2000-2005 period. 

Other HRSA Activities. H.R. 4807 would require that formula 
grants reauthorized under Parts A and B use the number of HIV 
disease cases and AIDS cases in the distribution formulas in fiscal 
year 2005 and subsequent years. This provision would have no di- 
rect impact on federal spending. The bill would require the federal 
government to assist states with the new data requirements that 
would directly raise their program costs. 



51 



Part A grants. The bill would extend indefinitely the requirement 
that 50 percent of appropriated funds for Part A be disbursed with- 
in 60 days after the appropriation becomes available. (Those funds 
are disbursed in the form of formula grants.) A "hold harmless" 
provision in the bill would also change the limit on the amount by 
which grants to states could decline from year to year. Those provi- 
sions would affect the distribution of annual appropriations and the 
expedited disbursement might affect the pattern at which such ap- 
propriations would be spent during the year (by increasing the 
amounts disbursed within 60 days of appropriation), but CBO an- 
ticipates that they would not affect total program spending. 

Part B grants. Section 206 of the bill would double the minimum 
Part B base award to $200,000 for states with fewer than 90 living 
cases of AIDS and to $500,000 for states with 90 or more living 
cases of AIDS. It would also add the Federated States of Micro- 
nesia and the Republic of Palau as entities eligible to receive Part 
B funds. The bill also would modify the hold harmless formula for 
Part B grants. CBO estimates those changes would cost less than 
$500,000 in 2001 and $4 million over the 2001-2005 period. 

Additional HRSA activities and reports. H.R. 4807 would require 
several new activities by the Secretary of HHS and many new 
studies and reports. The Secretary, through the Administrator of 
HRSA and in consultation with grant recipients, would be required 
to conduct a review of several administrative procedures for grants 
provided under Parts A and B, and develop new coordinated and 
more efficient procedures. Submission of the various plans for im- 
plementing such changes to the Congress would be due within 18 
to 24 months of enactment. 

The bill also would require that the Secretary provide training 
manuals and guidance materials to the Planning Council members 
who make allocation decisions about Part A grants. It also would 
require that the Secretary develop national quantitative incidence 
data and design a mechanism for its use in making awards for the 
supplemental grant money that goes to states demonstrating "se- 
vere need." 

The bill also would require that the Secretary of HHS, in con- 
sultation with others, develop a plan regarding appropriate care 
following the release of prisoners with HIV disease within two 
years following enactment. 

H.R. 4807 would require federal coordination among federal HIV 
programs concerning planning, funding, and implementation 
issues. This provision would affect programs administered by 
HRSA, CDC, the Substance Abuse and Mental Health Services Ad- 
ministration, and the Health Care Financing Administration. The 
bill would require biannual reports to the Congress with an anal- 
ysis of the federal barriers to HIV program integration, including 
proposals to eliminate those barriers, as well as a status report on 
the coordination efforts at the federal, state, and local levels. 

The Secretary would be required to request that the Institute of 
Medicine (IOM) complete a study, within two years after the enact- 
ment of H.R. 4807, regarding the appropriate epidemiological 
measures and their relationship to health-related support services 
for certain individuals with HIV. The Secretary would have to re- 
port to the Congress within 90 days of the request's completion. 
The bill also would require that the Secretary request IOM to con- 



52 



duct a study on the reliability of surveillance systems used by the 
states and to issue recommendations to improve those systems 
within three years of enactment. H.R. 4807 also would require that 
the Secretary request IOM to conduct a study within 18 months of 
enactment on perinatal transmission of HIV across the states, in- 
cluding an analysis of barriers to the testing of newborns and preg- 
nant women, and to provide state-by-state recommendations to re- 
duce perinatal transmission of HIV. 

CBO estimates those activities and reports would cost about $1 
million in 2001 and $5 million over 2001 through 2005. 

New HRSA programs 

In addition to reauthorizing current programs and making cer- 
tain programmatic changes, the bill would provide authorizations 
for two new provisions in the Ryan White CARE Act that would in- 
crease program costs. The estimated appropriations authorized in 
the bill for these provisions is also shown in Table 2. 

New Supplemental Grants for Certain States. Section 207 of H.R. 
4807 would create a new supplemental grant program to meet HIV 
care and support needs in areas that are not eligible for Part A 
grants. The Secretary of HHS would be required to reserve 50 per- 
cent of the increase in funding for Part B grants (other than that 
earmarked for state AIDS drug assistance programs, or ADAPs) for 
these supplemental grants— which would be awarded competitively 
to states in "severe need" for additional resources. However, the 
program would not begin until the amount appropriated under 
Part B (excluding ADAP funds) is $20 million higher than the 
amount appropriated in 2000. Under the inflation-adjusted as- 
sumptions used for this estimate such a trigger would not be 
reached until 2004. CBO estimates that the new program would 
have no effect on federal spending in 2001 but would cost $3 mil- 
lion over the 2001-2005 period. 

Compliant Partner Notification Program. H.R. 4807 would estab- 
lish a new grant program for partner notification, counseling, and 
referral services. States would have to cooperate with CDC and 
comply with certain requirements, including information sharing 
between states, to be eligible to receive funds. The bill would au- 
thorize $30 million for this program in 2001 and such sums as nec- 
essary through 2005. Assuming appropriation of the necessary 
amounts, CBO estimates that implementing this provision would 
cost $6 million in 2001 and a total of $121 million through 2005. 

NIH activities and reports 

H.R. 4807 would direct the Secretary, through the Director of the 
NIH, to examine the distribution and availability of HIV-related 
clinical research programs for women, infants, children, and youth. 
Although H.R. 4807 does not require submission of a report to the 
Congress, CBO believes the bill's intent is to have the results of the 
evaluation transmitted to the Congress. The bill also would require 
that NIH expand its research efforts in the development of rapid 
HIV tests and to provide progress reports to the Congress. CBO es- 
timates that those provisions would cost less than $500,000 in 2001 
and $5 million over the 2001-2005 period. 



53 



CDC activities and reports 

H.R. 4807 would authorize a new program for CDC to collect 
data and provide information support to the Ryan White program 
and its grantees for planning and evaluation activities. Based on 
the resources CDC currently devotes to supporting the improve- 
ment of states' HIV surveillance systems, CBO estimates that up 
to an additional 40 percent of that amount would be needed, or 
about $25 million starting in fiscal year 2001. It also would require 
that the Secretary, in consultation with CDC and the Food and 
Drug Administration, submit an analysis of issues surrounding pre- 
market reviews and commercial distribution of rapid HIV tests of 
the Congress within 90 days of enactment. In addition, the bill 
would require the CDC to establish guidelines for the use of rapid 
HIV tests, with specific recommendations for states, hospitals, and 
other entities on the availability of HIV tests for administration to 
pregnant women in labor or in late-stage pregnancy with unknown 
HIV status. CBO estimates that those activities and reports would 
increase costs by $9 million in 2001 and $105 million over the 
2001-2005 period. 

Pay-as-you-go considerations: None. 

Estimated impact on state, local, and tribal governments: The 
bill contains an intergovernmental mandate as defined in UMRA 
because it would require states to implement recommendations by 
the Institute on Medicine for increasing the routine testing of preg- 
nant women and newborn children for HIV. States would be re- 
quired to submit reports that describe their progress toward imple- 
menting the recommendations and barriers in the state that inhibit 
an obstetrician's ability to routinely test pregnant women and new- 
born infants for HIV. 

The bill also would authorize $30 million annually in grants for 
testing and treating case of perinatal HIV. CBO assumes that 
states would be allowed to use these grants to comply with the 
intergovernmental mandate and that the costs of the mandate 
would be well below that amount. The bill also would expand the 
purposes for which a number of grants could be used, including 
outpatient ambulatory and support services, inpatient case man- 
agement, and early intervention. Additional requirements for 
grants include increased outreach, data collection, and implementa- 
tion of quality management procedures. Such requirements would 
not be intergovernmental mandates as defined in UMRA because 
they are conditions of federal assistance. 

Estimated impact on the private sector: The bill contains no pri- 
vate-sector mandates as defined in UMRA. 

Previous CBO estimate: On May 10, 2000, CBO transmitted a 
cost estimate for S. 2311, the Ryan White CARE Act Amendments 
of 2000, as ordered reported by the Senate Committee on Health, 
Education, Labor, and Pensions on April 12, 2000. The two bills 
would make different changes to the Ryan White CARE Act, and 
the two estimates reflect those differences. 

Estimated prepared by: Federal Costs: For HRSA: Julia M. 
Christensen. For CDC: Jeanne M. De Sa. For NIH: Christopher J. 
Topoleski. Impact on State, Local, and Tribal Governments: Leo 
Lex. Impacts on the Private Sector: Jennifer Bullard. 

Estimate approved by: Peter H. Fontaine, Deputy Assistant Di- 
rector for Budget Analysis. 



54 



Federal Mandates Statement 

The Committee adopts as its own the estimate of Federal man- 
dates prepared by the Director of the Congressional Budget Office 
pursuant to section 423 of the Unfunded Mandates Reform Act. 

Advisory Committee Statement 

No advisory committees within the meaning of section 5(b) of the 
Federal Advisory Committee Act were created by this legislation. 

Constitutional Authority Statement 

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House 
of Representatives, the Committee finds that the Constitutional au- 
thority for this legislation is provided in Article I, section 8, clause 
3, which grants Congress the power to regulate commerce with for- 
eign nations, among the several States, and with the Indian tribes. 

Applicability to Legislative Branch 

The Committee finds that the legislation does not relate to the 
terms and conditions of employment or access to public services or 
accommodations within the meaning of section 102(b)(3) of the Con- 
gressional Accountability Act. 

Section-by-Section Analysis of the Legislation 
Section 1. Short title; table of contents 

This section provides the short title of the legislation, the "Ryan 
White CARE Act Amendments of 2000," and includes a table of 
contents. 

TITLE I — EMERGENCY RELIEF FOR AREAS WITH 
SUBSTANTIAL NEED FOR SERVICES 

Subtitle A— HIV Health Services Planning Councils 
Section 101. Membership of councils 

Subsection (a) changes the requirements for representation on an 
HIV Health Services Planning Council. Under current law, the 
Council must reflect in its composition the demographics of the epi- 
demic in the eligible area. New language requires that the Council 
reflect in its composition the demographics of the population of in- 
dividuals with HIV disease in the eligible area. This subsection 
clarifies the requirement that representatives to the Council from 
affected communities must include people with HIV disease. Rep- 
resentatives to the Council who are grantees under other Federal 
HIV programs may include providers of HIV prevention services. 
This subsection also adds the new requirement that the Council in- 
clude representatives of individuals who formerly were Federal, 
State, or local prisoners, were released from the custody of the 
penal system during the preceding three years, and had HIV dis- 
ease when so released. 

Subsection (b) establishes a new requirement that at least 33% 
of the Council must be individuals who are receiving HIV-related 
services under Part A, the Emergency Relief Grant Program, must 
not be officers, employees, or consultants to any entity receiving 



55 



such a grant, and do not represent such entity. An individual will 
be considered as receiving such services if the individual is the par- 
ent or caregiver of a minor child who is receiving HIV services. 
This restriction does not apply to entities receiving grants under 
other parts of the Ryan White CARE Act. 

Section 102. Duties of councils 

Section 102(a) adds to the duties of the HIV Health Service Plan- 
ning Council the requirements to determine the size and demo- 
graphics of the population of individuals with HIV disease and the 
needs of the population, with particular attention to individuals 
with HIV disease who are not receiving HIV-related services, and 
disparities in access and services among affected subpopulations 
and historically under served communities. 

This provision also rewrites current law on priorities that the 
Council must take into account in allocating of funds. The Council 
must take into account the size and demographics of the population 
with HIV disease; the demonstrated (or probable) cost effectiveness 
and outcome effectiveness of proposed strategies; the priorities of 
the communities for whom the services are intended; the avail- 
ability of government and nongovernmental sources of funding, in- 
cluding Medicaid and the SCHIP program; and the capacity devel- 
opment needs in historically underserved areas. In developing a 
comprehensive plan for the organization and delivery of health and 
support services, the Council must include a strategy for identi- 
fying individuals with HIV disease who are not receiving services 
and for enabling such individuals to utilize the services, giving par- 
ticular attention to eliminating disparities, and including discrete 
goals, a timetable, and an appropriate allocation of funds and a 
strategy to coordinate the provision of such services with programs 
for HIV prevention and for the prevention and treatment of sub- 
stance abuse. The plan must be compatible with any State or local 
plan providing HIV services. The Council must coordinate with 
Federal grantees that provide HIV-related services within their 
area. 

After receipt of a report by the Institute of Medicine, the Sec- 
retary of Health and Human Services, in consultation with entities 
that receive grants under Part A and Part B, must develop epi- 
demiologic measures for establishing the number of individuals liv- 
ing with HIV disease who are not receiving HIV-related services 
and carrying out the duties of the Council. 

The Secretary must provide guidelines and materials for training 
members of the planning Council regarding their duties to each 
chief elected official receiving a grant under Part A. 

Section 103. Open meetings; other additional provisions 

This section sets forth additional provisions with respect to pub- 
He deliberations of the Planning Council. The Council may not be 
chaired solely by an employee of the grantee under Part A. Fur- 
ther, Council meetings must be open to the public and held after 
adequate notice and documents prepared by or made available to 
the Council must be made available for public inspection and copy- 
ing. The Council must keep detailed minutes and their accuracy 
must be certified by the Council chair. This section does not apply 



56 



to the disclosure of personal information that would constitute an 
invasion of privacy, including medical or personnel matters. 

Subtitle B— Type and Distribution of Grants 
Section 111. Formula grants 

Subsection (a) changes current law, which states that Part A 
grant funds for eligible areas must be distributed not later than 60 
days after such funds are made available "for each of the fiscal 
years 1996 through 2000." The amendment applies to a generic fis- 
cal year. 

Subsection (b) provides that, for grants made for FY2005 and 
subsequent fiscal years, the cases counted for each 12-month period 
beginning on or after July 1, 2004, must be cases of HIV disease 
(as confirmed by the Centers for Disease Control and Preven- 
tion(CDC)) rather than cases of acquired immune deficiency syn- 
drome as under current law. The update of the yearly percentages 
used to determine grant amounts must be reported to the congres- 
sional committees of jurisdiction and, as applicable, the updates 
must take into account HIV cases. This subsection also requires the 
Secretary to determine whether sufficiently accurate and reliable 
data exists on cases of HIV disease. If the Secretary determines, 
by July 1, 2004, that there is not sufficiently accurate and reliable 
data on cases of HIV disease from all eligible areas, then references 
in this section to cases of HIV disease do not have any legal effect. 
From amounts appropriated for CDC grants on data collection, the 
Secretary is required to reserve funds to make grants and provide 
technical assistance to States and eligible areas for obtaining data 
on cases of HIV disease to ensure that data on such cases is avail- 
able from all States and eligible areas as soon as practicable but 
not later than the beginning of FY2007. 

Subsection (c) revises the limitation on the reduction in funding 
for a grant from one fiscal year to the next which may occur in cer- 
tain eligible areas. Under current law, grants made under Part A 
for fiscal year 2000 cannot be less than 95% of the amount received 
by the eligible area in fiscal year 1995. This provision stipulates 
that for each fiscal year in a protection period for an eligible area, 
the amount of the grant is increased to ensure that: (1) for the first 
fiscal year in the protection period, the grant is not less than 98% 
of the amount of the grant made for the base year for the protec- 
tion period; (2) for any second fiscal year in such period, the grant 
is not less than 95.7% of the base year grant; (3) for any third fiscal 
year in such period, the grant is not less than 91.1% of the base 
year grant; (4) for any fourth fiscal year, the grant is not less than 
84.2% of the base year grant; and (5) for any fifth or subsequent 
fiscal year in such period, the grant is not less than 75% of the 
base year grant. This provision also defines the base year for a pro- 
tection period as the fiscal year preceding the trigger grant-reduc- 
tion year. Further, it defines the first trigger grant-reduction year 
as the first fiscal year (after FY2000) for which the grant for the 
area is less than the grant for the preceding fiscal year. A protec- 
tion period begins with the trigger grant-reduction year and con- 
tinues until the beginning of the first fiscal year for which the 
grant equals or exceeds the amount of the grant for the base year. 
Any subsequent trigger grant-reduction year is the first fiscal year 



57 



after the end of the preceding protection period, for which the grant 
is less than the grant for preceding fiscal year. 

Section 112. Supplemental grants 

Current law provides a series of factors to be given priority con- 
sideration in awarding supplemental grants, Subsection (a) directs 
that the Secretary must count "severe need" as one-third when 
weighing factors to determine supplemental grant amounts. It also 
adds as new factors in determining severe need the current preva- 
lence of HIV disease, the increasing need for HIV-related services, 
and unmet need for such services. Further, it directs the Secretary 
to develop a mechanism to use national, quantitative incidence 
data not later than 18 months after the enactment. The mechanism 
should be modified to reflect the findings of the IOM report on epi- 
demiological measures and health care for individuals with HTV 
disease. 

Subsection (b) makes conforming amendments to the statute. 
Subtitle C— Other Provisions 
Section 121. Use of amounts 

The legislation makes some technical changes to the general pri- 
mary purposes for the use of grant funds under Part A regarding 
outpatient and ambulatory health or support services, and inpa- 
tient case management. Subsection (a) specifically defines out- 
patient and ambulatory support services as including case manage- 
ment, to the extent that such services facilitate, support, or sustain 
the delivery, or benefits of health services. It also includes outreach 
activities as a new general primary purpose for the use of grant 
amounts. The outreach activities are intended to identify individ- 
uals with HTV disease who are not receiving HIV-related services. 

Subsection (b) authorizes the use of Title I grants for early inter- 
vention services. (Under current law, such services are only pro- 
vided under Title III.) The entities which may receive grants for 
such services include: public health departments, emergency rooms, 
substance abuse and mental health treatment programs, detoxifica- 
tion centers, detention facilities, clinics regarding sexually trans- 
mitted diseases, homeless shelters, HIV disease counseling and 
testing sites, State health care points of entry or eligible areas, fed- 
erally qualified health centers, and entities providing early inter- 
vention services. The entity must demonstrate to the chief elected 
official that Federal, State, or local funds are inadequate for the 
services to be provided and that the entity will supplement and not 
supplant other available funds for such services. 

Subsection (c) specifies that the chief elected official must estab- 
lish a quality management program to assess the extent to which 
services are consistent with Public Health Service guidelines for 
the treatment of HIV disease, and as applicable, to develop strate- 
gies to ensure that such services are consistent with the guidelines. 
Restricts spending on such program to the lesser of 5% of the Title 
I grant received or $3 million. 

Section 122. Application 

In addition to other assurances specified under current law that 
are to be included on an application, entities within an eligible area 



58 



that receive grant funds must maintain relationships with appro- 
priate entities in the area, including those conducting early inter- 
vention services. 

Section 123. Review of administrative costs and compensation 

Each chief elected official must ensure, not later than one year 
after the date of enactment of this legislation, that the planning 
Council reviews available data on the administrative costs (includ- 
ing financial compensation and benefits) of entities receiving 
grants; and determines whether compensation of any officers or 
employees of such entities exceeds that of the chief elected official. 

TITLE II -CARE GRANT PROGRAM 

Subtitle A— General Grant Provisions 

Section 201. Priority for women, infants, and children 

Under current law, a priority for services is provided for women, 
infants, and children; this section adds youth to this group. 

Section 202. Use of grants 

Under current law, Part B grants funds may be used to provide 
a variety of health services for individuals and families with HIV 
disease including: outpatient and ambulatory health and support 
services; inpatient case management; outreach activities; establish- 
ment and operation of HIV care consortia; home-based and commu- 
nity-based care services; continuity of health insurance coverage; 
and, therapeutics to treat HIV disease. This section specifies that 
States may use Part B grant funds for: (1) support services, includ- 
ing case management, to the extent that such services facilitate, 
support, or sustain the delivery, or benefits of health services for 
individuals and families with HIV disease; (2) outreach activities 
that are intended to identify individuals with HIV disease who are 
not receiving HlV-related services; (3) early intervention services 
(under current law, such services are only provided under Title III); 
and (4) quality management program to assess the extent to which 
services are consistent with Public Health Service guidelines for 
the treatment of HIV disease, and as applicable, to develop strate- 
gies to ensure that such services are consistent with the guidelines. 
It also restricts spending on quality management to the lesser of 
5% of the Part B grant received or $3 million. (The guidelines and 
restrictions governing Part B grants for quality management are 
the same as those required for Part A.) 

Section 203. Grants to establish HIV CARE consortia 

This section adds new language regarding the assurances and 
the application submitted by a consortium to a State for Part B 
grant assistance. Current law requests that a consortium provide 
a number of assurances along with the application to a State for 
Part B grant funds. It stipulates that a consortium must provide 
the State with assurances that it has identified populations with 
HIV disease, particularly those experiencing disparities in access 
and services and those who reside in historically underserved com- 
munities. In addition, the consortium must provide assurances that 
its service plan is consistent with the State comprehensive plan for 



59 



the organization and delivery of HIV health care and support serv- 
ices. The consortium must also demonstrate in the application for 
Part B grant funds that adequate planning occurred to address dis- 
parities in access and services in historically underserved commu- 
nities. 

Section 204. Provision of treatments 

This section makes changes in how States may use funds under 
Part B to provide treatments for individuals with HIV disease. 
Current law authorizes States to provide prescription drugs to low- 
income individuals with HIV disease. New language allows a State 
to expend grants to pay, on behalf of individuals with HIV disease, 
the costs of purchasing or maintaining health insurance or plans 
whose coverage includes a full range of such therapeutics and ap- 
propriate primary care services. 

Section 205. State application 

Subsection (a) makes additions to the information that must be 
included in the State application for Part B funds (these changes 
are similar to those made to the duties of the Planning Council 
under Title). This subsection specifies that a State application must 
contain determinations of: (1) the size and demographics of the 
population of individuals with HIV disease; and (2) the needs of the 
population, with particular attention to individuals with HIV dis- 
ease who are not receiving HIV-related services, and disparities in 
access and services among affected subpopulations and historically 
underserved communities. 

The State application must provide a comprehensive plan that, 
in addition to current law requirements, establishes priorities for 
the allocation of funds based on: size and demographics of the pop- 
ulation with HIV disease; the availability of other governmental 
and nongovernmental resources; the capacity development needs 
resulting from disparities in the availability of HIV-related services 
in historically underserved communities and rural communities; 
and the efficiency of the administrative mechanism of the State for 
rapidly allocating funds to the areas of greatest need. The com- 
prehensive plan must also include: (1) a strategy for identifying in- 
dividuals with HIV disease who are not receiving services and for 
enabling such individuals to utilize the services, giving particular 
attention to eliminating disparities, and including discrete goals, a 
timetable, and an appropriate allocation of funds; and (2) a strat- 
egy to coordinate the provision of such services with programs for 
HTV prevention and for the prevention and treatment of substance 
abuse. 

Subsection (b) revises the public hearing process. Current law 
provides that the public health agency administering the grant for 
the State will conduct public hearings concerning the proposed use 
and distribution of funds received under Part B. This subsection 
specifies that the public health agency administering the grant for 
the State must engage in a public advisory planning process, in- 
cluding public hearings, when developing the comprehensive plan 
for the State application. This public advisory planning process 
must include the same participants represented when developing 
the statewide coordinated statement of need and shall to the extent 
possible include entities described in section 2602(b)(2). 



60 



Subsection (c) requires that, along with the State application for 
Part B funds, the State must provide an assurance that entities lo- 
cated within areas in which grant activities are carried out must 
maintain relationships with appropriate entities in the area, in- 
cluding those providing early intervention services. 

Section 206. Distribution of funds 

Subsection (a) doubles the minimum allotments for grants under 
Part B. For States with less than 90 living cases of AIDS, the min- 
imum grant is $200,000 instead of $100,000 in current law. The 
minimum grant for States with 90 or more living cases of AIDS is 
$500,000 instead of $250,000 in current law. In addition, each ter- 
ritory is eligible for a minimum funding level of $50,000; current 
law does not provide a minimum funding level for territories. 

Current law uses an estimate of the number of living cases of 
AIDS within the State or territory in the formula which determines 
the amount of a State grant under Part B. Subsection (b) provides 
that when estimating living cases for grants made for FY2005 and 
subsequent fiscal years, the cases counted for each 12-month pe- 
riod beginning on or after July 1, 2004, shall be cases of HIV dis- 
ease (as confirmed by CDC) rather than cases of AIDS, as in cur- 
rent law. However, if the Secretary determines by July 1, 2004, 
that there is not sufficiently accurate and reliable data on cases of 
HIV disease from all eligible areas, then references in this section 
to cases of HIV disease do not have any legal effect. 

Subsection (c) revises the limitation on the reduction in funding 
for a grant from one fiscal year to the next which may occur in cer- 
tain States. 

Subsection (d) provides that each territory is eligible for a min- 
imum funding level of $50,000, duplicating a change made in this 
bill by section 206, subsection (a). 

Subsection (e) authorizes the Secretary to reserve 2% of AIDS 
drug assistance program funds to make grants to States whose 
HIV patients have a need for therapeutics that is not being met by 
the current ADAP program within the State. These grants are dis- 
cretionary grants and not formula grants. It also requires such 
grants to be distributed not later than 240 days after ADAP funds 
become available. States must match such grants with non-federal 
contributions of not less than 25% of the costs. 

In current law, the term "territory of the United States" is de- 
fined as American Samoa, the Commonwealth of the Northern 
Mariana Islands and the Republic of the Marshall Islands. "State" 
is defined as the 50 States, the District of Columbia, the Common- 
wealth of Puerto Rico, the Virgin Islands, and Guam. Subsection (f) 
amends the definition of the territories to include the Federated 
States of Micronesia, the Republic of Palau, and for purposes of de- 
termining minimum grant level, the Commonwealth of Puerto Rico. 

Section 207. Supplemental grants for certain states 

This section removes a section of current law, which is replaced 
by section 413. A new supplemental grant program is created for 
States that have eligible communities with a severe need for com- | 
prehensive HIV-related services and which are not eligible for 
grants under Part A. States must submit an application that de- 
tails the need for services in such communities. The program be- 



61 



comes effective when the amount appropriated to Title II (exclud- 
ing ADAP) is at least $20 million greater than the appropriation 
for Title II in FY2000. 

Subtitle B— Provisions Concerning Pregnancy and Perinatal 
Transmission of HIV 

Section 211. Repeals 

This section repeals provisions regarding the testing of pregnant 
women and newborn infants. 

Section 212. Grants 

Subsection (a) includes treatment services, in accordance with 
applicable recommendations of the Secretary, for pregnant women 
(with HIV disease) and their infants as an additional purpose for 
making grants. Under current law, this section allows the Sec- 
retary to make grants to States that have adopted the CDC guide- 
lines on HIV counseling and voluntary testing of pregnant women. 
Such grants are used for: counseling pregnant women on HIV dis- 
ease; outreach efforts to women at risk of HIV who are not receiv- 
ing prenatal care; voluntary testing; and, offsetting various State 
costs in implementing this section. Authorizes $30 million for each 
of fiscal years 2001 through 2005. When such appropriations are in 
excess of $10 million, the Secretary must reserve a percentage for 
making grants to States that under law have a requirement that 
all newborn infants be tested for HIV disease; or a requirement 
that newborn infants born in the State be tested for HIV disease 
where the attending obstetrician does not know the HIV status of 
the mother. The percentages to be reserved are: 25% for FY2001, 
50% for FY2002, 50% for FY2003, 75% for FY2004, and 75% for 
FY2005. No grant may exceed $4 million and if the reserved 
amounts are not obligated, then the requirement to reserve such 
amounts will not apply. A State in receipt of such funds under this 
section must agree that the grant will supplement and not sup- 
plant other available funds to carry out the purposes of the grant. 

Subsection (b) establishes a special funding rule if FY2001 appro- 
priations are less than $14 million for this section. The Secretary 
is required to reserve certain amounts from increased FY2001 
funding for Title II that is above such appropriations for FY2000. 

Section 213. Study by Institute of Medicine 

This section adds a new section requiring the Secretary to re- 
quest that the Institute of Medicine conduct a study to: (1) deter- 
mine the number of newborn infants with HIV born in the United 
States where the attending obstetrician did not know the HIV sta- 
tus of the mother; (2) determine State barriers that prevent or dis- 
courage an obstetrician from making it a routine practice to offer 
pregnant women an HIV test and a routine practice to test new- 
born infants for HIV disease in circumstances in which the obste- 
trician does not know the HIV status of the mother; and (3) provide 
recommendations for each State for reducing perinatal trans- 
mission of HIV. It requires the report to be submitted to the appro- 
priate congressional committees, the Secretary, and the chief public 
health official of each State. Beginning in FY2004, each State is re- 
quired to report to the Secretary on progress being made toward 



62 



meeting such recommendations. For FY2005 and each subsequent 
fiscal year, the State must demonstrate that it has made reason- 
able progress toward meeting the recommendations. If the State 
has not made reasonable progress, the State must cooperate with 
the CDC Director in carrying out activities toward meeting the rec- 
ommendations, and the State must submit a report to the Sec- 
retary containing a description of any barriers that continue to 
exist in the State and a description of how the State intends to re- 
duce the incidence of perinatal HIV cases. The Secretary must 
make funds under section 212 grants available to the States for the 
purposes of this section and is required to submit the State reports 
to the appropriate congressional committees. 

The Committee recognizes that the IOM completed a report on 
this topic in 1998. It is not the intent of the Committee to duplicate 
any material compiled for that report. The study is to make broad 
recommendations for each State to and assist States in reducing 
the incidence of perinatal HIV transmission. The Committee recog- 
nizes that some States have had few, if any, such cases in recent 
years. An analysis of the efforts of these states may provide useful 
information to states that continue to have higher rates of 
perinatal HIV transmission. 

Subtitle C— Certain Partner Notification Programs 
Section 221. Grants for compliant partner notification programs 

This section adds a new subpart to the Ryan White CARE Act 
that provides grants for partner notification programs. It author- 
izes appropriations of $30 million for FY2001 and such sums as 
necessary for each of the fiscal years 2002 through 2005 for grants 
to States to carry out programs to provide partner counseling and 
referral services. In order to receive a grant under this new sub- 
part, a State must have the following policies in effect: (1) a pro- 
gram for partner notification to inform partners of individuals with 
HIV disease that the partners may have been exposed to HIV; (2) 
a system for confidentially reporting positive test results for HIV; 
(3) specific counseling and referral measures; (4) reports to CDC on 
the number of individuals solicited for names of partners, the num- 
ber who provided the names, and the number of notified partners; 
(5) cooperation with CDC in a national program of partner notifica- 
tion in which information is shared between public health officers 
of the States. In making grants, the Secretary must give preference 
for each of the fiscal years FY2001 through FY2003 to States 
whose reporting systems for cases of HIV disease produce suffi- 
ciently accurate and reliable data. A State may not receive a grant 
for FY2004 or subsequent fiscal years unless its reporting system 
produces reliable data. 

TITLE III— EARLY INTERVENTION SERVICES 

Subtitle A— Formula Grants for States 

Section 301. Repeal of program 

This section repeals subpart I of part C of title XXVI of the 
PHSA. (Subpart I was not reauthorized in 1995.) Subpart I pro- 
vided formula grants to States for early intervention services such 
as HIV testing and counseling, other clinical or diagnostic services, 



63 



and referrals to providers of health support services or biomedical 
research facilities. 

Subtitle B— Categorical Grants 
Section 311. Preferences in making grants 

Under current law, the Secretary must give preference to any 
qualified applicants that are experiencing an increase in the bur- 
den of providing services regarding HIV disease. This new provi- 
sion adds that the Secretary must give preference to those that will 
expend the grant to provide services in underserved or rural areas. 

Section 312. Planning and development grants 

Current law allows the use of planning and development grants 
to assist entities in expanding their capacity to provide early inter- 
vention services. Subsection (a) provides that the grants are to be 
used to assist entities in expanding their capacity to provide serv- 
ices, including early intervention, in low-income communities and 
affected subpopulations that are underserved. Such grants may not 
be used to purchase or improve land, or to purchase, construct, or 
permanently improve any building or other facility. 

Current law provides that planning grants under this section to 
provide early intervention services may not exceed $50,000. Sub- 
section (b) specifies that grants for early intervention services 
under paragraph (1)(A) may not exceed $50,000, and grants for ca- 
pacity development for low-income and underserved populations 
under paragraph (1)(B) may not exceed $150,000 and their dura- 
tion may not exceed three years. 

Subsection (c) increases to five percent (currently one percent) 
the amount of appropriations for this subpart that may be used to 
carry out this section. 

Section 313. Authorization of appropriations 

This section extends authorized appropriations of such sums as 
necessary for this subpart for each of the fiscal years 2001 through 
2005. 

Subtitle C— General Provisions 
Section 321. Provision of certain counseling services 

Presently, current law specifies what additional information 
(such as early interventions services, health care referrals) is to be 
conveyed to an individual receiving a positive result on an HIV 
test. This section adds new language specifying that when grant 
applicants counsel individuals regarding a positive HIV test result, 
they must provide counseling that: (1) emphasizes the duty of in- 
fected individuals to disclose their infected status to their sexual 
partners and their partners in the sharing of hypodermic needles; 
(2) provides advice on the manner in which such disclosures can be 
made; and (3) emphasizes the continuing duty to avoid any behav- 
iors that will expose others to HIV. 

Section 322. Additional required agreements 

This section adds new language provides that the applicant will 
not expend more than 10%, instead of the current 7.5%, for admin- 



64 



istrative expenses, including planning and evaluation of the grant. 
In addition, new language specifies that applicants are required to 
establish a quality management program to assess the extent to 
which medical services under this title are consistent with the most 
recent Public Health Service guidelines for the treatment of HIV 
disease and related opportunistic infections and that improvements 
in access to and quality of medical services are addressed. 

TITLE IV— OTHER PROGRAMS AND ACTIVITIES 

Subtitle A— Certain Programs for Research, Demonstrations, or 

Training 

Section 401. Grants for coordinated services and access to research 
for women, infants, children, and youth 

This section removes language in current law specifying that a 
significant number of women, infants, children and youth who are 
patients of the applicant will be participating in research projects. 
This section provides new language specifying that grant appli- 
cants must demonstrate linkages to research and how access to 
such research is being offered to patients. The Secretary, in coordi- 
nation with the Director of the National Institutes of Health (NIH), 
is required to examine the distribution and availability of appro- 
priate HIV-reiated research projects to enhance and expand HIV- 
related research, especially in communities that are under rep- 
resented with respect to such projects. Grantees must also imple- 
ment a quality management program. Authorized appropriations 
are extended through FY2005. 

Section 402. AIDS education and training centers 

The Committee believes that the Dental Reimbursement Pro- 
gram is a cost-effective program that provides quality oral health 
care to people living with HIV/AIDS, and trains providers to effec- 
tively and safely deliver care to these patients. The Committee has 
reauthorized the program and maintained its current format of pro- 
viding retrospective reimbursement to dental schools and residency 
programs. In addition, the Committee has established new grants 
for community-based care to support collaborative efforts between 
dental education programs and community-based providers di- 
rected at providing oral health care to patients with HIV disease 
in currently unserved areas and communities without dental edu- 
cation programs. 

Although the Dental Program has been successful, there is still 
a large HIV/AIDS population that has not benefitted because there 
is not a dental education institution participating in their area. 
These patients are also in need of dental services that could be pro- 
vided at community sites if more community-based providers would 
partner with a dental school or residency program. In these part- 
nerships, dental students or residents could provide treatment for 
HIV/AIDS patients in underserved communities under the direc- 
tion of a community-based dentist who would serve as adjunct fac- 
ulty. By encouraging dental educational institutions to partner 
with community-based providers, the Committee intends to address 
the unmet need in these areas by ensuring that dental treatment 



65 



for the HIV/AIDS population is available in all areas of the coun- 
try, not just where dental schools are located. 

Current law allows eligible entities to use grant funds for the 
training of health personnel in the diagnosis, treatment and pre- 
vention of HIV disease, including the prevention of the perinatal 
transmission of the disease and the prevention and treatment of 
opportunistic infections. Subsection (a) provides that grants may be 
used to train health professionals in prenatal and other gyneco- 
logical care for women with HIV disease. The Secretary may also 
make grants to such entities to develop protocols for the medical 
care of women with HIV disease, including prenatal and other gyn- 
ecological care. In addition, the bill directs the Secretary to, not 
later than 90 days after enactment, issue and begin implementa- 
tion of a strategy for the dissemination of HIV treatment informa- 
tion to health care providers and patients. 

Under current law, the Secretary may make grants to assist 
schools and programs with respect to oral health care to patients 
with HIV disease. Such schools and programs include: (1) dental 
schools and post doctoral dental education programs; and (2) dental 
hygiene programs that are accredited by the Commission on Dental 
Accreditation. Subsection (b) provides that the Secretary may also 
make grants to schools and programs, as described in the previous 
sentence, that partner with community-based dentists to provide 
oral health care to patients with HIV disease in unserved areas. 
The partnerships must permit the training of dental students and 
residents and the participation of community dentists as adjunct 
faculty. 

Subsection (c) authorizes appropriations of such sums as nec- 
essary for programs under this section for fiscal years 2001 
through 2005. 

Subtitle B- General Provisions in Title XXVI 
Section 411. Evaluations and reports 

This section authorizes appropriations for the Secretary to evalu- 
ate programs under the Ryan White CARE Act for each of the fis- 
cal years 2001 through 2005. 

Section 412. Data collection through centers for disease control and 
prevention 

This section redesignates section 2675 as section 2675A, and 
adds a new section 2675 which authorizes appropriations to the 
Secretary (acting through the Director of CDC) of such sums as 
may be necessary for each of the fiscal years 2001 through 2005 to 
collect and provide data for program planning and evaluation ac- 
tivities. That authorization is in addition to other authorizations 
for such purpose. 

Section 413. Coordination 

Current law provides that the Secretary will assure that the 
Health Resources and Services Administration (HRSA) and CDC 
will coordinate the planning and funding of programs authorized 
under this title to assure that health support services for individ- 
uals with HIV disease are integrated with each other and that the 
continuity of care of individuals with HIV is enhanced. This section 

HRpt. 106-788 D-00--3 



66 



provides that the Secretary must ensure that there is coordination 
of the planning, funding, and implementation of Federal HIV pro- 
grams regarding continuity of care and prevention services among 
the following agencies: HRSA, CDC, SAMHSA, and the Health 
Care Financing Administration (HCFA). In addition, the Secretary 
must consult with other Federal agencies, including the Depart- 
ment of Veterans Affairs, as needed and utilize planning informa- 
tion submitted to such agencies by the States. This section also re- 
quires that the Secretary report biennially to the appropriate con- 
gressional committees on the coordination efforts at the Federal, 
State, and local levels. The report should include a description of 
Federal barriers to HIV program integration and a strategy for 
eliminating such barriers. It also inserts "prevention services" after 
the term "continuity of care" each place the term appears. 

Section 414. Plan regarding release of prisoners with HIV disease 

This section adds a new subsection to section 2675A which di- 
rects the Secretary to develop a plan for the medical case manage- 
ment of and the provision of support services to individuals who 
were Federal or State prisoners and had HIV disease on the date 
they were released from custody. The Secretary must consult with 
the Attorney General, the Director of the Bureau of Prisons, the 
States, eligible areas and certain grant recipients in developing 
such plan. The Secretary must report to the Congress on such a 
plan not later than two years after the date of enactment of this 
legislation. 

Section 415. Audits 

Section 2675B stipulates that for FY2002 and subsequent fiscal 
years, the Secretary may reduce grant amounts to a State or polit- 
ical subdivision of a State for a fiscal year, if the State or subdivi- 
sion fails to prepare audits for the second preceding fiscal year. The 
Secretary must annually submit representative samples of such au- 
dits to the Congress. 

Section 416. Administrative simplification 

Section 2675C requires the Secretary, after consultations with 
specified entities receiving grants under this title, to: (1) Develop 
a plan for coordinating the disbursement of grants to eligible areas 
under Part A with the disbursement of grants to States under Part 
B; (2) make a determination on whether the efficiency of grantees 
would be improved by their submitting applications biennially 
rather than annually; and (3) develop a plan for simplifying the 
process for applications by eligible areas under Part A and States 
under Part B. The Secretary must submit both plans to the Con- 
gress not later than 18 months after the date of enactment of this 
bill. The Secretary must submit the determination to Congress not 
later than 2 years after the date of enactment. The Secretary must 
complete implementation of both plans not later than 2 years after 
the date of their submission. 

Section 41 7. Authorization of appropriations for Parts A and B 

This section authorizes appropriations for fiscal years 2001 
through 2005 to carry out Part A (Title I) grants to eligible areas, 
and Part B (Title II) CARE grants to States. 



67 



TITLE V- GENERAL PROVISIONS 
Section 501. Studies by Institute of Medicine 

Subsection (a) requires that the Secretary ask the Institute of 
Medicine to conduct a study that provides the following: (1) a deter- 
mination of whether the surveillance system of each State regard- 
ing HIV provides for the reporting of cases of infection in a manner 
that is sufficient to provide adequate and reliable information on 
the number of such cases and the demographic characteristics of 
such cases, both for the State in general and for specific geographic 
areas; (2) a determination of whether such information is suffi- 
ciently accurate for purposes of grant formulas to eligible areas 
under Part A and States under Part B; and (3) recommendations 
on the manner in which a State can improve its surveillance sys- 
tem. 

Subsection (b) requires that the Secretary ask the Institute of 
Medicine to conduct a study on appropriate epidemiologic measures 
and their relation to the financing and delivery of health services 
to low-income, uninsured and underinsured people living with HIV 
disease. The study should consider existing and needed health care 
and epidemiological data and its relation to efficiency and effective- 
ness of care delivery, quality of care, resource allocation, and access 
to HIV services. The study should also determine the actual costs, 
potential savings, and financial impact of modifying the Medicaid 
program to establish eligibility for medical assistance on the basis 
of HIV infection rather than providing assistance only if the infec- 
tion has progressed to AIDS. 

Subsection (c) authorizes the Secretary to contract with other en- 
tities if the Institute of Medicine declines to conduct the study. 
Subsection (d) directs the Secretary to report to the appropriate 
congressional committees not later than three years after the date 
of enactment of this Act for the surveillance study, and not later 
than two years after enactment for the epidemiological study. 

Section 502. Development of rapid HTV test 

Subsection (a) requires the Director of NIH to expand, intensify, 
and coordinate research and other activities of NIH for the develop- 
ment of reliable and affordable tests for HIV disease that can rap- 
idly be administered and whose results can be rapidly obtained. 
Requires periodic progress reports to the appropriate congressional 
committees. It also authorizes appropriations as necessary for 
FY2001 through 2005. 

Subsection (b) requires that the Secretary, in consultation with 
the Director of CDC and the Commissioner of Food and Drugs, sub- 
mit to the appropriate committees a report describing the progress 
made towards, and barriers to, the premarket review and commer- 
cial distribution of rapid HIV tests. The report must (1) to assess 
the public health need for, and benefits of, rapid HIV tests; (2) 
make recommendations regarding the need for expedited review of 
rapid HIV test applications submitted to the Center for Biologies 
Evaluation and Research (including criteria for expedited review 
for favorable recommendations); and (3) specify whether the bar- 
riers to premarket review include the unnecessary application of 
requirements concerning donor screening. 



68 



Subsection (c) requires that the Director of CDC, promptly after 
commercial distribution of a rapid HIV test begins, establish or up- 
date guidelines that include recommendations for States, hospitals, 
and other appropriate entities regarding the ready availability of 
such tests for administration to pregnant women who are in labor 
or in the late stage of pregnancy and whose HIV status is not 
known to the attending obstetrician. 

TITLE VI —EFFECTIVE DATE 
Section 601. Effective date 

This section establishes the effective date of the legislation as Oc- 
tober 1, 2000, or upon the date of its enactment, whichever occurs 
later. 

Changes in Existing Law Made by the Bill, as Reported 

In compliance with clause 3(e) of rule XIII of the Rules of the 
House of Representatives, changes in existing law made by the bill, 
as reported, are shown as follows (existing law proposed to be omit- 
ted is enclosed in black brackets, new matter is printed in italic, 
existing law in which no change is proposed is shown in roman): 

PUBLIC HEALTH SERVICE ACT 

TITLE XXVI-HIV HEALTH CARE 
SERVICES PROGRAM 

Part A— Emergency Relief for Areas With Substantial Need 

for Services 

SEC. 2602. ADMINISTRATION AND PLANNING COUNCIL. 

(a) * * * 

(b) HIV Health Services Planning Council.— 

(1) Establishment.— To be eligible for assistance under this 
part, the chief elected official described in subsection (a)(1) 
shall establish or designate an HIV health services planning 
council that shall reflect in its composition the [demographics 
of the epidemic in the eligible area involved,] demographics of 
the population of individuals with HIV disease in the eligible 
area involved, with particular consideration given to dispropor- 
tionately affected and historically underserved groups and sub- 
populations. Nominations for membership on the council shall 
be identified through an open process and candidates shall be 
selected based on locally delineated and publicized criteria. 
Such criteria shall include a conflict-of-interest standard that 
is in accordance with paragraph (5). 

(2) Representation.— The HIV health services planning 
council shall include representatives of— 

(A) * * * 

******* 



69 



(G) affected communities, including people with HIV dis- 
ease [or AIDS] and historically underserved groups and 
subpopulations; 

******* 

(K) grantees under section 2671, or, if none are oper- 
ating in the area, representatives of organizations with a 
history of serving children, youth, women, and families liv- 
ing with HIV and operating in the area; [and] 

(L) grantees under other Federal HIV programs [.], in- 
cluding but not limited to providers of HIV prevention serv- 
ices; and 

(M) representatives of individuals who formerly were 
Federal, State, or local prisoners, were released from the 
custody of the penal system during the preceding three 
years, and had HIV disease as of the date on which the in- 
dividuals were so released. 

(3) Method of providing for council. — 

(A) * * * 

[(C) Chairperson.— A planning council may not be 
chaired solely by an employee of the grantee.] 

(4) Duties.— The planning council established or designated 
under paragraph (1) shall— 

(A) determine the size and demographics of the popu- 
lation of individuals with HIV disease; 

(B) determine the needs of such population, with par- 
ticular attention to — 

(i) individuals with HIV disease who are not receiv- 
ing HIV-related services; and 

(ii) disparities in access and services among affected 
subpopulations and historically underserved commu- 
nities; 

[(A)] (C) establish priorities for the allocation of funds 
within the eligible area, including how best to meet each 
such priority and additional factors that a grantee should 
consider in allocating funds under a grant based on the— 
[(i) documented needs of the HIV-infected popu- 
lation; 

[(ii) cost and outcome effectiveness of proposed 
strategies and interventions, to the extent that such 
data are reasonably available (either demonstrated or 
probable); 

[(iii) priorities of the HIV-infected communities for 
whom the services are intended; and 

[(iv) availability of other governmental and non- 
governmental resources;] 

(i) size and demographics of the population of indi- 
viduals with HIV disease (as determined under sub- 
paragraph (A)) and the needs of such population (as 
determined under subparagraph (B)); 

(ii) demonstrated (or probable) cost effectiveness and 
outcome effectiveness of proposed strategies and inter- 



70 



ventions, to the extent that data are reasonably avail- 
able; 

(Hi) priorities of the communities with HIV disease 
for whom the services are intended; 

(iv) availability of other governmental and non- 
governmental resources to provide HJV-related services 
to individuals and families with HIV disease, includ- 
ing the State plan under title XIX of the Social Secu- 
rity Act (relating to the Medicaid program) and the 
program under title XXI of such Act (relating to the 
program for State children's health insurance); and 

(v) capacity development needs resulting from dis- 
parities in the availability of HIV -related services in 
historically underserved communities; 

[(B) develop a comprehensive plan for the organization 
and delivery of health services described in section 2604 
that is compatible with any existing State or local plan re- 
garding the provision of health services to individuals with 
HIV disease;] 

(D) develop a comprehensive plan for the organization 
and delivery of health and support services described in 
section 2604 that — 

(i) includes a strategy for identifying individuals 
with HIV disease who are not receiving such services 
and for informing the individuals of and enabling the 
individuals to utilize the services, giving particular at- 
tention to eliminating disparities in access and services 
among affected subpopulations and historically under- 
served communities, and including discrete goals, a 
timetable, and an appropriate allocation of funds; 

(ii) includes a strategy to coordinate the provision of 
such services with programs for HIV prevention and 
for the prevention and treatment of substance abuse, 
including programs that provide comprehensive treat- 
ment services for such abuse; and 

(Hi) is compatible with any State or local plan for the 
provision of services to individuals with HIV disease; 

[(C)] (E) assess the efficiency of the administrative 
mechanism in rapidly allocating funds to the areas of 
greatest need within the eligible area, and at the discre- 
tion of the planning council, assess the effectiveness, either 
directly or through contractual arrangements, of the serv- 
ices offered in meeting the identified needs; 

[(D)] (F) participate in the development of the statewide 
coordinated statement of need initiated by the State public 
health agency responsible for administering grants under 
part B; [and] 

[(E)] (G) establish methods for obtaining input on com- 
munity needs and priorities which may include [public 
meetings,] public meetings (in accordance with paragraph 
(7)), conducting focus groups, and convening ad-hoc 
panels [.]; and 

(H) coordinate with Federal grantees that provide HFV- 
related services within the eligible area. 

******* 



71 



(5) Conflicts of interest. — 
(A) * * * 

* * * * s}: * s[c 

f CJ Composition of council. — TTie following applies re- 
garding the membership of a planning council under para- 
graph (1): 

(i) Not less than 33 percent of the council shall be in- 
dividuals who are receiving HlY-related services pur- 
suant to a grant under section 2601(a), are not officers, 
employees, or consultants to any entity that receives 
amounts from such a grant, and do not represent any 
such entity, and reflect the demographics of the popu- 
lation of individuals with HIV disease as determined 
under paragraph (4)(A). For purposes of the preceding 
sentence, an individual shall be considered to be receiv- 
ing such services if the individual is a parent of, or a 
caregiver for, a minor child who is receiving such serv- 
ices. 

(ii) With respect to membership on the planning 
council, clause (i) may not be construed as having any 
effect on entities that receive funds from grants under 
any of parts B through F but do not receive funds from 
grants under section 2601(a), on officers or employees 
of such entities, or on individuals who represent such 
entities. 

(7) Public deliberations. — With respect to a planning coun- 
cil under paragraph (1), the following applies: 

(A) The council may not be chaired solely by an employee 
of the grantee under section 2601(a). 

(B) In accordance with criteria established by the Sec- 
retary: 

(i) The meetings of the council shall be open to the 
public and shall be held only after adequate notice to 
the public. 

(ii) The records, reports, transcripts, minutes, agen- 
da, or other documents which were made available to 
or prepared for or by the council shall be available for 
public inspection and copying at a single location. 

(Hi) Detailed minutes of each meeting of the council 
shall be kept. The accuracy of all minutes shall be cer- 
tified to by the chair of the council. 

(iv) This subparagraph does not apply to any disclo- 
sure of information of a personal nature that would 
constitute a clearly unwarranted invasion of personal 
privacy, including any disclosure of medical informa- 
tion or personnel matters. 

* % * * % * * 

(d) Process for Establishing Allocation Priorities. - 
Promptly after the date of the submission of the report required in 
section 501(b) of the Ryan White CARE Act Amendments of 2000 
(relating to the relationship between epidemiological measures and 
health care for certain individuals with HIV disease), the Secretary, 



72 



in consultation with entities that receive amounts from grants under 
section 2601(a) or 2611, shall develop epidemiologic measures — 

(1) for establishing the number of individuals living with 
HIV disease who are not receiving HTV-related health services; 
and 

(2) for carrying out the duties under subsection (b)(4) and sec- 
tion 2617(b). 

(e) Training Guidance and Materials. — The Secretary shall 
provide to each chief elected official receiving a grant under 2601(a) 
guidelines and materials for training members of the planning 
council under paragraph (1) regarding the duties of the council. 

SEC. 2603. TYPE AND DISTRIBUTION OF GRANTS. 

(a) Grants Based on Relative Need of Area. — 

* * * 

(2) Expedited distribution.— Not later than 60 days after 
an appropriation becomes available to carry out this part [for 
each of the fiscal years 1996 through 2000] for a fiscal year, 
the Secretary shall, except in the case of waivers granted 
under section 2605(c), disburse 50 percent of the amount ap- 
propriated under section 2677 for such fiscal year through 
grants to eligible areas under section 2601(a), in accordance 
with paragraph (3). The Secretary shall reserve an additional 
percentage of the amount appropriated under section 2677 for 
a fiscal year for grants under part A to make grants to eligible 
areas under section 2601(a) in accordance with paragraph (4). 

(3) Amount of grant. — 

(A) * * * 

* * * * * * * 

(C) Estimate of ldting cases.— The amount determined 
in this subparagraph is an amount equal to the product 
of- 

(i) the number of cases of acquired immune defi- 
ciency syndrome in the eligible area during each year 
in the most recent 120-month period for which data 
are available with respect to all eligible areas, as indi- 
cated by the number of such cases reported to and con- 
firmed by the Director of the Centers for Disease Con- 
trol and Prevention for each year during such period, 
except that (subject to subparagraph (D)), for grants 
made pursuant to this paragraph for fiscal year 2005 
and subsequent fiscal years, the cases counted for each 
12-month period beginning on or after July 1, 2004, 
shall be cases of HIV disease ( as reported to and con- 
firmed by such Director) rather than cases of acquired 
immune deficiency syndrome; and 

(ii) with respect to— 

(j) * * * 

******* 

(X) the tenth year during such period, .88. 
The yearly percentage described in subparagraph (ii) shall 
be updated biennially by the Secretary, after consultation 
with the Centers for Disease Control and Prevention, and 
shall be reported to the congressional committees of juris- 
diction. The first such update shall occur prior to the de- 



73 



termination of grant awards under this part for fiscal year 
1998. Updates shall as applicable take into account the 
counting of cases of HW disease pursuant to clause (i). 
(D) Determination of secretary regarding data on 

HIV CASES. — 

(U In GENERAL. -Not later than July 1, 2004, the 
Secretary shall determine whether there is data on 
cases of HIV disease from all eligible areas ''reported to 
and confirmed by the Director of the Centers for Dis- 
ease Control and Prevention) sufficiently accurate and 
reliable for use for purposes of subparagraph f C/ij. In 
making such a determination, the Secretary shall take 
into consideration the findings of the study under sec- 
tion 501 f bj of the Ryan White CARE Act Amendments 
of 2000 ^relating to the relationship between epidemio- 
logical measures and health care for certain individ- 
uals with HIV disease;, the fiscal impact of the use of 
such data, the impact of the use of such data on the 
organization and delivery of HIV -related services in eli- 
gible areas, and the fiscal impact of not using such 
data. 

f iij Effect of adverse determination.— If under 
clause Cij the Secretary determines that data on cases 
of HIV disease is not sufficiently accurate and reliable 
for use for purposes of subparagraph f C/ij, then not- 
withstanding such subparagraph, for any fiscal year 
prior to fiscal year 2007 the references in such sub- 
paragraph to cases of HIV disease do not have any 
legal effect. 

(iU) Grants and technical assistance regarding 
COINTING OF HIV CASES. -Of the amounts appro- 
priated under section 2675 for a fiscal year, the Sec- 
retary shall reserve amounts to make grants and pro- 
vide technical assistance to States and eligible areas 
with respect to obtaining data on cases of HIV disease 
to ensure that data on such cases is available from all 
States and eligible areas as soon as is practicable but 
not later than the beginning of fiscal year 2007, 
['Dj] E Unexpended funds.— The Secretary may. m 
determining the amount of a grant for a fiscal year under 
this paragraph, adjust the grant amount to reflect the 
amount of unexpended and uncanceled grant funds re- 
maining at the end of the fiscal year preceding the year for 
which the grant determination is to be made. The amount 
of any such unexpended funds shall be determined using 
the financial status report of the grantee. 
[(4) Increase IN grant.— With respect to an eligible area 
under section 2601(a), the Secretary shall increase the amount 
of a grant under paragraph (2) for a fiscal year to ensure that 
such eligible area receives not less than— 

[ A) with respect to fiscal year 1996 ; 100 percent: 

[ B I with respect to fiscal year 1997. 99 percent; 

[ C I with respect to fiscal year 1998. 98 percent: 

[ D) with respect to fiscal year 1999. 96.5 percent: and 

[ E with respect to fiscal year 2000,. 95 percent; 



74 



of the amount allocated for fiscal year 1995 to such entity 
under this subsection.] 

(4) Increases in grant. — 

(A) In general. —For each fiscal year in a protection pe- 
riod for an eligible area, the Secretary shall increase the 
amount of the grant made pursuant to paragraph (2) for 
the area to ensure that— 

(i) for the first fiscal year in the protection period, 
the grant is not less than 98 percent of the amount of 
the grant made for the eligible area pursuant to such 
paragraph for the base year for the protection period; 

(ii) for any second fiscal year in such period, the 
grant is not less than 95.7 percent of the amount of 
such base year grant; 

(Hi) for any third fiscal year in such period, the 
grant is not less than 91.1 percent of the amount of the 
base year grant; 

(iv) for any fourth fiscal year in such period, the 
grant is not less than 84.2 percent of the amount of the 
base year grant; and 

( v) for any fifth or subsequent fiscal year in such pe- 
riod, the grant is not less than 75 percent of the 
amount of the base year grant. 

(B) Base year; protection period. — With respect to 
grants made pursuant to paragraph (2) for an eligible area: 

(i) The base year for a protection period is the fiscal 
year preceding the trigger grant-reduction year. 

(ii) The first trigger grant-reduction year is the first 
fiscal year (after fiscal year 2000) for which the grant 
for the area is less than the grant for the area for the 
preceding fiscal year. 

(Hi) A protection period begins with the trigger 
grant-reduction year and continues until the beginning 
of the first fiscal year for which the amount of the 
grant for the area equals or exceeds the amount of the 
grant for the base year for the period. 

(iv) Any subsequent trigger grant-reduction year is 
the first fiscal year, after the end of the preceding pro- 
tection period, for which the amount of the grant is less 
than the amount of the grant for the preceding fiscal 
year. 

(b) Supplemental Grants.— 

(1) In general.— Not later than 150 days after the date on 
which appropriations are made under section 2677 for a fiscal 
year, the Secretary shall disburse the remainder of amounts 
not disbursed under section 2603(a)(2) for such fiscal year for 
the purpose of making grants under section 2601(a) to eligible 
areas whose application under section 2605(b)— 
(A) * * * 

(E) demonstrates that resources will be allocated in ac- 
cordance with the local demographic incidence of AIDS in- 



75 



eluding appropriate allocations for services for infants, 
children, youth, women, and families with HIV disease; 

******* 
(2) [Definition} Amount of grant.— 

(A) In GENERAL. — The amount of each grant made for 
purposes of this subsection shall be determined by the Sec- 
retary based on a weighting of factors under paragraph (1), 
with severe need under subparagraph (B) of such para- 
graph counting one-third. 

[(A)] (B) Severe need.— In determining severe need in 
accordance with paragraph (1)(B), the Secretary shall con- 
sider the ability of the qualified applicant to expend funds 
efficiently and the impact of relevant factors on the cost 
and complexity of delivering health care and support serv- 
ices to individuals with HIV disease in the eligible area, 
including factors such as— 

(i) sexually transmitted diseases, substance abuse, 
tuberculosis, severe mental illness, or other comorbid 
factors determined relevant by the Secretary; 

(ii) new or growing subpopulations of individuals 
with HIV disease; [and] 

(iii) homelessness[.]; 

(iv) the current prevalence of HIV disease; 

(v) an increasing need for HIV-related services, in- 
cluding relative rates of increase in the number of 
cases of HIV disease; and 

(vi) unmet need for such services, as determined 
under section 2602(b)(4). 

[(B)] (C) Prevalence.— In determining the impact of 
the factors described in subparagraph [(A)] (B), the Sec- 
retary shall, to the extent practicable, use national, quan- 
titative incidence data that are available for each eligible 
area. Not later than [2 years after the date of enactment 
of this paragraph] 18 months after the date of the enact- 
ment of the Ryan White CARE Act Amendments of 2000, 
the Secretary shall develop a mechanism to utilize such 
data. Such a mechanism shall be modified to reflect the 
findings of the study under section 501(b) of the Ryan 
White CARE Act Amendments of 2000 (relating to the rela- 
tionship between epidemiological measures and health care 
for certain individuals with HIV disease). In the absence 
of such data, the Secretary may consider a detailed de- 
scription and qualitative analysis of severe need, as deter- 
mined under subparagraph [(A)] (B), including any local 
prevalence data gathered and analyzed by the eligible 
area. 

[(C)] (D) Priority.— Subsequent to the development of 
the quantitative mechanism described in subparagraph 
[(B)] (C), the Secretary shall phase in, over a 3-year pe- 
riod beginning in fiscal year 1998, the use of such a mech- 
anism to determine the severe need of an eligible area 
compared to other eligible areas and to determine, in part, 
the amount of supplemental funds awarded to the eligible 
area under this part. 



76 



[(4) Amount of grant.— The amount of each grant made for 
purposes of this subsection shall be determined by the Sec- 
retary based on the application submitted by the eligible area 
under section 2605(b).] 

[(5)] (4) Failure to submit. — 
(A) * * * 

******* 

SEC. 2604. USE OF AMOUNTS. 

(a) * * * 

(b) Primary Purposes.— 

(1) In general.— The chief elected official shall use amounts 
received under a grant under section 2601 to provide direct fi- 
nancial assistance to entities described in paragraph (2) for the 
purpose of delivering or enhancing [HIV- 
related— ] HIV -related services, as follows: 

(A) [outpatient and ambulatory health and support serv- 
ices, including case management, substance abuse treat- 
ment and] Outpatient and ambulatory health services, in- 
cluding substance abuse treatment, mental health treat- 
ment, and comprehensive treatment services, which shall 
include treatment education and prophylactic treatment 
for opportunistic infections, for individuals and families 
with HIV disease [; and]. 

(B) Outpatient and ambulatory support services (includ- 
ing case management), to the extent that such services fa- 
cilitate, support, or sustain the delivery, or benefits of 
health services for individuals and families with HIV dis- 
ease. 

[(B) inpatient case management] (C) Inpatient case 
management services that prevent unnecessary hos- 
pitalization or that expedite discharge, as medically appro- 
priate, from inpatient facilities. 

(D) Outreach activities that are intended to identify indi- 
viduals with HIV disease who are not receiving HIV -related 
services, and that are — 

(i) necessary to implement the strategy under section 
2602(b)(4)(D), including activities facilitating the ac- 
cess of such individuals to HW-related primary care 
services at entities described in paragraph ( 3); 

(ii) conducted in a manner consistent with the re- 
quirements under sections 2605(a)(3) and 2651(b)(2); 
and 

(Hi) supplement, and do not supplant, such activities 
that are carried out with amounts appropriated under 
section 31 7. 

(3) Early intervention services. — 

(A) In general. — The purposes for which a grant under 
section 2601 may be used include providing to individuals 
with HIV disease early intervention services described in 
section 2651(b)(2) (including referrals under subparagraph 
(C) of such section), subject to subparagraph (B). The enti- 
ties through which such services may be provided under the 
grant include public health departments, emergency rooms, 



77 



substance abuse and mental health treatment programs, 
detoxification centers, detention facilities, clinics regarding 
sexually transmitted diseases, homeless shelters, HIV dis- 
ease counseling and testing sites, health care points of entry 
specified by States or eligible areas, federally qualified 
health centers, and entities described in section 2652(a). 

(B) Conditions. — With respect to an entity that proposes 
to provide early intervention services under subparagraph 
(A), such subparagraph applies only if the entity dem- 
onstrates to the satisfaction of the chief elected official for 
the eligible area involved that — 

(i) Federal, State, or local funds are otherwise inad- 
equate for the early intervention services the entity pro- 
poses to provide; and 

(ii) the entity will expend funds pursuant to such 
subparagraph to supplement and not supplant other 
funds available to the entity for the provision of early 
intervention services for the fiscal year involved. 

[(3)] (4) Priority for women, infants and children.— For 
the purpose of providing health and support services to infants, 
children, youth, and women with HIV disease, including treat- 
ment measures to prevent the perinatal transmission of HIV, 
the chief elected official of an eligible area, in accordance with 
the established priorities of the planning council, shall use, 
from the grants made for the area under section 2601(a) for a 
fiscal year, not less than the percentage constituted by the 
ratio of the population in such area of infants, children, youth, 
and women with acquired immune deficiency syndrome to the 
general population in such area of individuals with such syn- 
drome. 

(c) Quality Management. — 

(1) Requirement. — The chief elected official of an eligible 
area that receives a grant under this part shall provide for the 
establishment of a quality management program to assess the 
extent to which HIV health services provided to patients under 
the grant are consistent with the most recent Public Health 
Service guidelines for the treatment of HIV disease and related 
opportunistic infection, and as applicable, to develop strategies 
for ensuring that such services are consistent with the guide- 
lines. 

(2) Use OF FUNDS.— From amounts received under a grant 
awarded under this part for a fiscal year, the chief elected offi- 
cial of an eligible area may (in addition to amounts to which 
subsection (f)(1) applies) use for activities associated with the 
quality management program required in paragraph (1) not 
more than the lesser of— 

(A) 5 percent of amounts received under the grant; or 

(B) $3,000,000. 

[(c)] (d) Limited Expenditures for Personnel Needs.— 
^-jj * * * 

******* 

[(d)] (e) Requirement of Status as Medicaid Provider.— 

* * * 

[(e)] (f) Administration.— 



78 



(1) In general.— The chief executive officer of an eligible 
area shall not use in excess of 5 percent of amounts received 
under a grant awarded under this part for administration. In 
the case of entities and subcontractors to which such officer al- 
locates amounts received by the officer under the grant, the of- 
ficer shall ensure that, of the aggregate amount so allocated, 
the total of the expenditures by such entities for administrative 
expenses does not exceed 10 percent (without regard to wheth- 
er particular entities expend more than 10 percent for such ex- 
penses). 

[(f)] (g) Construction.— A State may not use amounts received 
under a grant awarded under this part to purchase or improve 
land, or to purchase, construct, or permanently improve (other than 
minor remodeling) any building or other facility, or to make cash 
payments to intended recipients of services. 

SEC. 2605. APPLICATION. 

(a) In General.— To be eligible to receive a grant under section 
2601, an eligible area shall prepare and submit to the Secretary an 
application, in accordance with subsection (c) regarding a single ap- 
plication and grant award, at such time, in such form, and con- 
taining such information as the Secretary shall require, including 

assurances adequate to ensure— 

* * * 

(3) that entities within the eligible area that receive funds 
under a grant under section 2601(a) will maintain relation- 
ships with appropriate entities in the area, including entities 
described in section 2604(b)(3); 

[(3)] (4) that entities within the eligible area that will re- 
ceive funds under a grant provided under section 2601(a) shall 
participate in an established HIV community-based continuum 
of care if such continuum exists within the eligible area; 

[(4)] (5) that funds received under a grant awarded under 
this part will not be utilized to make payments for any item 
or service to the extent that payment has been made, or can 
reasonably be expected to be made, with respect to that item 
or service— 

(A) under any State compensation program, under an in- 
surance policy, or under any Federal or State health bene- 
fits program; or 

(B) by an entity that provides health services on a pre- 
paid basis; 

[(5)] (6) to the maximum extent practicable, that— 

(A) HIV health care and support services provided with 
assistance made available under this part will be provided 

without regard— 

/•^ * * * 

sjs * * * * * * 

[(6)] (7) that the applicant has participated, or will agree to 
participate, in the statewide coordinated statement of need 
process where it has been initiated by the State public health 
agency responsible for administering grants under part B, and 



79 



ensure that the services provided under the comprehensive 
plan are consistent with the statewide coordinated statement 
of need. 

* * * * * * * 

Part B— Care Grant Program 
Subpart I— General Grant Provisions 

SEC. 2611. GRANTS. 

(a) * * * 

(b) Priority for Women, Infants and Children.— For the pur- 
pose of providing health and support services to infants, children, 
youth, and women with HIV disease, including treatment measures 
to prevent the perinatal transmission of HIV, a State shall use, of 
the funds allocated under this part to the State for a fiscal year, 
not less than the percentage constituted by the ratio of the popu- 
lation in the State of infants, children, youth, and women with ac- 
quired immune deficiency syndrome to the general population in 
the State of individuals with such syndrome. 

SEC. 2612. GENERAL USE OF GRANTS. 

(a) In General.— A State may use amounts provided under 

grants made under this part— 

(]j * * * 

(b) Support Services; Outreach. — The purposes for which a 
grant under this part may be used include delivering or enhancing 
the following: 

(1) Support services under section 2611(a) (including case 
management) to the extent that such services facilitate, support, 
or sustain the delivery, or benefits of health services for individ- 
uals and families with HIV disease. 

(2) Outreach activities that are intended to identify individ- 
uals with HIV disease who are not receiving HIV-related serv- 
ices, and that are — 

(A) necessary to implement the strategy under section 
2617(b)(4)(B); 

(B) conducted in a manner consistent with the require- 
ment under section 261 7(b)( 6)( G); and 

( C) supplement, and do not supplant, such activities that 
are carried out with amounts appropriated under section 
317. 

( c) Early Intervention Services. — 

(1) In general. — The purposes for which a grant under this 
part may be used include providing to individuals with HIV 
disease early intervention services described in section 
2651(b)(2) (including referrals under subparagraph (C) of such 
section), subject to paragraph (2). The entities through which 
such services may be provided under the grant include public 
health departments, emergency rooms, substance abuse and 
mental health treatment programs, detoxification centers, deten- 
tion facilities, clinics regarding sexually transmitted diseases, 
homeless shelters, HIV disease counseling and testing sites, 



80 



health care points of entry specified by States or eligible areas, 
federally qualified health centers, and entities described in sec- 
tion 2652(a). 

(2) Conditions. — With respect to an entity that proposes to 
provide early intervention services under paragraph (1), such 
paragraph applies only if the entity demonstrates to the satis- 
faction of the State involved that — 

(A) Federal, State, or local funds are otherwise inad- 
equate for the early intervention services the entity proposes 
to provide; and 

(B) the entity will expend funds pursuant to such para- 
graph to supplement and not supplant other funds avail- 
able to the entity for the provision of early intervention 
services for the fiscal year involved. 

(d) Quality Management. - 

(1) Requirement.— Each State that receives a grant under 
this part shall provide for the establishment of a quality man- 
agement program to assess the extent to which HTV health serv- 
ices provided to patients under the grant are consistent with the 
most recent Public Health Service guidelines for the treatment 
of HIV disease and related opportunistic infection, and as ap- 
plicable, to develop strategies for ensuring that such services are 
consistent with the guidelines. 

(2) USE OF FUNDS.— From amounts received under a grant 
awarded under this part for a fiscal year, the State may (in ad- 
dition to amounts to which section 2618(c)(5) applies) use for 
activities associated with the quality management program re- 
quired in paragraph (1) not more than the lesser of— 

(A) 5 percent of amounts received under the grant; or 

(B) $3,000,000. 

SEC. 2613. GRANTS TO ESTABLISH HIV CARE CONSORTIA. 

(a) * * * 

(b) Assurances. — 

(1) Requirement.— To receive assistance from a State under 
subsection (a), an applicant consortium shall provide the State 
with assurances that— 

(A) within any locality in which such consortium is to 
operate, the populations and subpopulations of individuals 
and families with HIV disease have been identified by the 
consortium, particularly those experiencing disparities in 
access and services and those who reside in historically un- 
derserved communities', 

(B) the service plan established under subsection (c)(2) 
by such consortium is consistent with the comprehensive 
plan under 2617(b)(4) and addresses the special care and 
service needs of the populations and subpopulations identi- 
fied under subparagraph (A); and 

* * * * * * * 

(c) Application.— 

(1) In general.— To receive assistance from the State under 
subsection (a), a consortium shall prepare and submit to the 
State, an application that— 

(A) * * * 

******* 



81 



(D) demonstrates that the consortium has created a 
mechanism to evaluate periodically— 

(j) * * * 

(ii) the cost-effectiveness of the mechanisms em- 
ployed by the consortium to deliver comprehensive 
care; [and] 

(E) demonstrates that the consortium will report to the 
State the results of the evaluations described in subpara- 
graph (D) and shall make available to the State or the Sec- 
retary, on request, such data and information on the pro- 
gram methodology that may be required to perform an 
independent e valuation [.]; and 

(F) demonstrates that adequate planning occurred to ad- 
dress disparities in access and services and historically un- 
der served communities. 

(2) Consultation.— In establishing the plan required under 
paragraph (1)(B), the consortium shall consult with— 

(A) * * * 

(B) not less than one community-based organization that 
is organized solely for the purpose of providing HlV-re- 
lated support services to individuals with HIV disease; 
[and] 

(C) grantees under section 2671, or, if none are oper- 
ating in the area, representatives in the area of organiza- 
tions with a history of serving children, youth, women, and 
families living with HIV[.]; and 

(D) entities described in section 2602(b)(2). 

The organization to be consulted under subparagraph (B) shall 
be at the discretion of the applicant consortium. 

SEC. 2616. PROVISION OF TREATMENTS. 

(a) * * * 

jfj 5{S * * * * * 

(e) Use of Health Insurance and Plans. —In carrying out sub- 
section (a), a State may expend a grant under this part to provide 
the therapeutics described in such subsection by paying on behalf of 
individuals with HIV disease the costs of purchasing or maintain- 
ing health insurance or plans whose coverage includes a full range 
of such therapeutics and appropriate primary care services. 

SEC. 2617. STATE APPLICATION. 

(a) * * * 

(b) Description of Intended Uses and Agreements.— The ap- 
plication submitted under subsection (a) shall contain— 

* * * 

(2) a determination of the size and demographics of the popu- 
lation of individuals with HIV disease in the State; 

(3) a determination of the needs of such population, with par- 
ticular attention to — 

(A) individuals with HIV disease who are not receiving 
HTV-related services; and 

(B) disparities in access and services among affected sub- 
populations and historically underserved communities; 



82 



[(2)] (4) a [comprehensive plan for the organization] com- 
prehensive plan that describes the organization and delivery of 
HIV health care and support services to be funded with assist- 
ance received under this part that shall include a description 
of the purposes for which the State intends to use such 
assistance [, including—], and that — 

(A) establishes priorities for the allocation of funds with- 
in the State based on — 

(i) size and demographics of the population of indi- 
viduals with HTV disease (as determined under para- 
graph (2)) and the needs of such population (as deter- 
mined under paragraph (3)); 

(ii) availability of other governmental and non- 
governmental resources to provide HTV-related services 
to individuals and families with HIV disease; 

(Hi) capacity development needs resulting from dis- 
parities in the availability of HTV-related services in 
historically underserved communities and rural com- 
munities; and 

(iv) the efficiency of the administrative mechanism of 
the State for rapidly allocating funds to the areas of 
greatest need within the State; 

(B) includes a strategy for identifying individuals with 
HIV disease who are not receiving such services and for in- 
forming the individuals of and enabling the individuals to 
utilize the services, giving particular attention to elimi- 
nating disparities in access and services among affected 
subpopulations and historically underserved communities, 
and including discrete goals, a timetable, and an appro- 
priate allocation of funds; 

(C) includes a strategy to coordinate the provision of such 
services with programs for HIV prevention and for the pre- 
vention and treatment of substance abuse, including pro- 
grams that provide comprehensive treatment services for 
such abuse; 

[(A)] (D) describes the services and activities to be pro- 
vided and an explanation of the manner in which the ele- 
ments of the program to be implemented by the State with 
such assistance will maximize the quality of health and 
support services available to individuals with HIV disease 
throughout the State; 

[(B)] (E) provides a description of the manner in which 
services funded with assistance provided under this part 
will be coordinated with other available related services for 
individuals with HIV disease; and 

[(C)] (F) provides a description of how the allocation 
and utilization of resources are consistent with the state- 
wide coordinated statement of need (including traditionally 
underserved populations and subpopulations) developed in 
partnership with other grantees in the State that receive 
funding under this title; and 
[(3)] (5) an assurance that the public health agency admin- 
istering the grant for the State will periodically convene a 
meeting of individuals with HIV disease, representatives of 
grantees under each part under this title, providers, and public 



83 



agency representatives for the purpose of developing a state- 
wide coordinated statement of need; and 
[(4)] (6) an assurance by the State that— 

[(A) the public health agency that is administering the 
grant for the State will conduct public hearings concerning 
the proposed use and distribution of the assistance to be 
received under this part;] 

(A) the public health agency that is administering the 
grant for the State engages in a public advisory planning 
process, including public hearings, that includes the par- 
ticipants under paragraph (5), and entities described in 
section 2602(b)(2), in developing the comprehensive plan 
under paragraph (4) and commenting on the implementa- 
tion of such plan; 

(E) the State will maintain HIV-related activities at a 
level that is equal to not less than the level of such ex- 
penditures by the State for the 1-year period preceding the 
fiscal year for which the State is applying to receive a 
grant under this part; [and] 

(F) the State will ensure that grant funds are not uti- 
lized to make payments for any item or service to the ex- 
tent that payment has been made, or can reasonably be ex- 
pected to be made, with respect to that item or service— 

(i) * * * 

(ii) by an entity that provides health services on a 
prepaid basis [J; and 

(G) entities within areas in which activities under the 
grant are carried out will maintain relationships with ap- 
propriate entities in the area, including entities described 
in section 2612(c); 

SEC. 2618. DISTRIBUTION OF FUNDS. 

(b) Amount of Grant to State.— 

(1) Minimum allotment.— Subject to the extent of amounts 
made available under section 2677, the amount of a grant to 
be made under this part for— 

(A) each of the several States and the District of Colum- 
bia for a fiscal year shall be the greater of— 

(i) (I) with respect to a State or District that has less 
than 90 living cases of acquired immune deficiency 
syndrome, as determined under paragraph (2)(D), 
[$100,000] $200,000; or 

(II) with respect to a State or District that has 90 
or more living cases of acquired immune deficiency 
syndrome, as determined under paragraph (2)(D), 
[$250,000] $500,000; 

(ii) an amount determined under paragraph (2) and 
then, as applicable, increased under paragraph (2)(H); 
and 

(B) each territory of the United States, as defined in 
paragraph (3), shall be the greater of $50,000 or an amount 
determined under paragraph (2). 

(2) Determination. — 



84 



(A) Formula.— The amount referred to in paragraph 
(l)(A)(ii) for a State and paragraph (1)(B) for a territory of 
the United States shall be the product of— 

(i) an amount equal to the amount appropriated 
under section 2677 for the fiscal year involved for 
grants under part B, subject to [subparagraph (H)] 
subparagraphs (H) and (I); and 

(D) Estimate of living cases.— The amount determined 
in this subparagraph is an amount equal to the product 
of- 

(i) the number of cases of acquired immune defi- 
ciency syndrome in the State or territory during each 
year in the most recent 120-month period for which 
data are available with respect to all States and terri- 
tories, as indicated by the number of such cases re- 
ported to and confirmed by the Director of the Centers 
for Disease Control and Prevention for each year dur- 
ing such period, except that (subject to subparagraph 
(E)), for grants made pursuant to this paragraph for 
fiscal year 2005 and subsequent fiscal years, the cases 
counted for each 12-month period beginning on or after 
July 1, 2004, shall be cases of HIV disease (as reported 
to and confirmed by such Director) rather than cases 
of acquired immune deficiency syndrome', and 

(E) Determination of secretary regarding data on 
HIV CASES.— If under 2603(a)(3)(D)(i) the Secretary deter- 
mines that data on cases of HIV disease is not sufficiently 
accurate and reliable, then notwithstanding subparagraph 
(D) of this paragraph, for any fiscal year prior to fiscal year 
2007 the references in such subparagraph to cases of HIV 
disease do not have any legal effect. 

[(E)] (F) Puerto rico, virgin islands, guam.— For pur- 
poses of subparagraph (D), the cost index for Puerto Rico, 
the Virgin Islands, and Guam shall be 1.0. 

[(F)] (G) Unexpended funds.— The Secretary may, in 
determining the amount of a grant for a fiscal year under 
this subsection, adjust the grant amount to reflect the 
amount of unexpended and uncanceled grant funds re- 
maining at the end of the fiscal year preceding the year for 
which the grant determination is to be made. The amount 
of any such unexpended funds shall be determined using 
the financial status report of the grantee. 
[(G) Limitation.— 

[(i) In general.— The Secretary shall ensure that 
the amount of a grant awarded to a State or territory 
for a fiscal year under this part is equal to not less 
than— 

[(I) with respect to fiscal year 1996, 100 per- 
cent; 

[(II) with respect to fiscal year 1997, 99 percent; 
[(III) with respect to fiscal year 1998, 98 per- 
cent; 

[(IV) with respect to fiscal year 1999, 96.5 per- 
cent; and 



85 



[(V) with respect to fiscal year 2000, 95 percent; 
of the amount such State or territory received for fis- 
cal year 1995 under this part. In administering this 
subparagraph, the Secretary shall, with respect to 
States that will receive grants in amounts that exceed 
the amounts that such States received under this part 
in fiscal year 1995, proportionally reduce such 
amounts to ensure compliance with this subparagraph. 
In making such reductions, the Secretary shall ensure 
that no such State receives less than that State re- 
ceived for fiscal year 1995. 

[(h) Ratable reduction.— If the amount appro- 
priated under section 2677 and available for allocation 
under this part is less than the amount appropriated 
and available under this part for fiscal year 1995, the 
limitation contained in clause (i) shall be reduced by 
a percentage equal to the percentage of the reduction 
in such amounts appropriated and available.] 

(H) Limitation. — 

(i) In GENERAL. — The Secretary shall ensure that the 
amount of a grant awarded to a State or territory 
under section 2611 for a fiscal year is not less than — 

(I) with respect to fiscal year 2001, 99 percent; 

(II) with respect to fiscal year 2002, 98 percent; 

(III) with respect to fiscal year 2003, 97 percent; 

(IV) with respect to fiscal year 2004, 96 percent; 
and 

(V) with respect to fiscal year 2005, 95 percent; 
of the amount such State or territory received for fiscal 
year 2000 under such section. In administering this 
subparagraph, the Secretary shall, with respect to 
States or territories that will under such section receive 
grants in amounts that exceed the amounts that such 
States received under such section for fiscal year 2000, 
proportionally reduce such amounts to ensure compli- 
ance with this subparagraph. In making such reduc- 
tions, the Secretary shall ensure that no such State re- 
ceives less than that State received for fiscal year 2000. 

(ii) Ratable reduction.— If the amount appro- 
priated under section 2677 for a fiscal year and avail- 
able for grants under section 2611 is less than the 
amount appropriated and available under such section 
for fiscal year 2000, the limitation contained in clause 
(i) shall be reduced by a percentage equal to the per- 
centage of the reduction in such amounts appropriated 
and available. 

[(H) Appropriations for treatment drug program.— 
With respect to] 

(I) Appropriations for treatment drug program. - 

(i) Formula grants.— With respect to the fiscal year 
involved, if under section 2677 an appropriations Act 
provides an amount exclusively for carrying out sec- 
tion 2616, the portion of such amount allocated to a 
State shall be the product of— 

[(i)] (I) [100] 98 percent of such amount; and 



86 



[(ii)] (II) the percentage constituted by the ratio of 
the State distribution factor for the State (as deter- 
mined under subparagraph (B)) to the sum of the 
State distribution factors for all States. 

(ii) Supplemental treatment drug grants.— 

(I) In general. — With respect to the fiscal year 
involved, if under section 2677 an appropriations 
Act provides an amount exclusively for carrying 
out section 2616, and such amount is not less than 
the amount so provided for the preceding fiscal 
year, the Secretary shall reserve 2 percent of such 
amount for making grants to States whose popu- 
lation of individuals with HIV disease has, as de- 
termined by the Secretary, a need for quantities of 
therapeutics described in section 2616(a) greater 
than the quantities available pursuant to clause 
(i). Such a grant is available for purposes of ob- 
taining such therapeutics. The Secretary shall 
carry out this clause as a program of discretionary 
grants, and not as a program of formula grants. 

(II) Distribution of grants. -The Secretary 
shall disburse all amounts under grants under 
subclause (I) for a fiscal year not later than 240 
days after the date on which the amount referred 
to in such subclause with respect to section 2616 
becomes available. 

(III) Requirement of matching funds.— A 
condition for receiving a grant under subclause (I) 
is that the State agree to make available (directly 
or through donations from public or private enti- 
ties) non-Federal contributions toward the costs of 
obtaining the therapeutics involved in an amount 
that is not less than 25 percent of such costs (deter- 
mined in the same manner as under 
2617(d)(2)(A)). 

(3) Definitions.— As used in this subsection— 

(A) * * * 

(B) the term "territory of the United States" means, 
American Samoa, the Commonwealth of the Northern 
Mariana Islands, [and the Republic of the Marshall Is- 
lands] the Republic of the Marshall Islands, the Federated 
States of Micronesia, and the Republic of Palau, and only 
for purposes of paragraph (1) the Commonwealth of Puerto 
Rico. 

[SEC. 2621. COORDINATION. 

[The Secretary shall ensure that the Health Resources and Serv- 
ices Administration, the Centers for Disease Control and Preven- 
tion, and the Substance Abuse and Mental Health Services Admin- 
istration coordinate the planning and implementation of Federal 
HIV programs in order to facilitate the local development of a com- 
plete continuum of HIV-related services for individuals with HIV 
disease and those at risk of such disease. Not later than October 



87 



1, 1996, and biennially thereafter, the Secretary shall submit to the 
appropriate committees of the Congress a report concerning coordi- 
nation efforts under this title at the Federal, State, and local levels, 
including a statement of whether and to what extent there exist 
Federal barriers to integrating HIV-related programs.] 

SEC. 2621. SUPPLEMENTAL GRANTS. 

(a) In General.— From amounts available pursuant to subsection 
(d) for a fiscal year, the Secretary shall make grants to States that 
meet the conditions to receive grants under section 2611, and that 
have one or more eligible communities, for the purpose of providing 
in such communities comprehensive services of the type described in 
section 2612(a) to supplement the development and care activities, 
primary care, and support services otherwise provided in such com- 
munities by the State under a grant under section 2611. 

(b) Eligible Community. —For purposes of this section, the term 
"eligible community" means a geographic area that— 

(1) is not within any eligible area as defined in section 2607; 
and 

(2) has a severe need for supplemental financial assistance to 
combat the HIV epidemic, according to criteria developed by the 
Secretary in consultation with the States, including evidence of 
underserved or rural areas or both. 

(c) Application.— A grant under subsection (a) may be made to 
a State if the State submits to the Secretary, as part of the State 
application submitted under section 2617, such information as re- 
quired to apply for funds under this section as determined by the 
Secretary in consultation with the States. 

(d) Funding. — 

(1) In general.— For the purpose of making grants under 
subsection (a) for a fiscal year, the Secretary shall reserve 50 
percent of the amount specified in paragraph (2). 

(2) Increases in part b funding. — 

(A) In general.— For purposes of paragraph (1), the 
amount specified in this paragraph is the amount by which 
the amount appropriated under section 2677 for the fiscal 
year involved and available for carrying out part B is an 
increase over the amount so appropriated and available for 
the preceding fiscal year, subject to subparagraphs (B) and 
(C). 

(B) Initial allocation year. — The allocation under 
paragraph (1) shall not be made until the first fiscal year 
for which the amount appropriated under section 2677 for 
the fiscal year involved and available for carrying out part 
B is an increase of not less than $20,000,000 over the 
amount so appropriated and available for fiscal year 2000, 
subject to subparagraph ( C). 

(C) Exclusion regarding separate treatment drug 
GRANTS.— Each determination under subparagraph (A) or 
(B) of the amount appropriated under section 2677 for a 
fiscal year and available for carrying out part B shall be 
made without regard to any amount to which section 
2618(b)(2)(I)(i) applies. 



88 



Subpart II— Provisions Concerning Pregnancy 
and Perinatal Transmission of HIV 

SEC. 2625. CDC GUIDELINES FOR PREGNANT WOMEN. 

(a) * * * 

(c) Additional Funds Regarding Women and Infants.— 

(1) In general.— If a State provides the certification re- 
quired in subsection (a) and is receiving funds under part B for 
a fiscal year, the Secretary may (from the amounts available 
pursuant to paragraph (2)) make a grant to the State for the 
fiscal year for the following purposes: 

(A) * * * 

(F) Making available to pregnant women with HIV dis- 
ease, and to the infants of women with such disease, treat- 
ment services for such disease in accordance with applica- 
ble recommendations of the Secretary. 
[(2) Funding.— For purposes of carrying out this subsection, 
there are authorized to be appropriated $10,000,000 for each of 
the fiscal years 1996 through 2000. Amounts made available 
under section 2677 for carrying out this part are not available 
for carrying out this section unless otherwise authorized.] 

(2) Funding. — 

(A) Authorization of appropriations.— For the pur- 
pose of carrying out this subsection, there are authorized to 
be appropriated $30,000,000 for each of the fiscal years 
2001 through 2005. Amounts made available under section 
2677 for carrying out this part are not available for car- 
rying out this section unless otherwise authorized. 

(B) Allocations for certain states. — 

(i) In GENERAL. — Of the amounts appropriated under 
subparagraph (A) for a fiscal year in excess of 
$10,000,000, the Secretary shall reserve the applicable 
percentage under clause (ii) for making grants under 
paragraph (1) to States that under law (including 
under regulations or the discretion of State officials) 
have — 

(I) a requirement that all newborn infants born 
in the State be tested for HIV disease; or 

(II) a requirement that newborn infants born in 
the State be tested for HIV disease in cir- 
cumstances in which the attending obstetrician for 
the birth does not know the HIV status of the 
mother of the infant. 

(ii) Applicable percentage.— For purposes of 
clause (i), the applicable amount for a fiscal year is as 
follows: 

(I) For fiscal year 2001, 25 percent. 

(II) For fiscal year 2002, 50 percent. 

(III) For fiscal year 2003, 50 percent. 

(IV) For fiscal year 2004, 75 percent. 

(V) For fiscal year 2005, 75 percent. 



89 



(C) Certain provisions. -With respect to grants under 
paragraph (1) that are made with amounts reserved under 
subparagraph (B) of this paragraph: 

(i) Such a grant may not be made in an amount ex- 
ceeding $4,000,000. 

(ii) If pursuant to clause (i) or pursuant to an insuf- 
ficient number of qualifying applications for such 
grants (or both), the full amount reserved under sub- 
paragraph (B) for a fiscal year is not obligated, the re- 
quirement under such subparagraph to reserve 
amounts ceases to apply. 

******* 

(4) Maintenance of effort. -A condition for the receipt of 
a grant under paragraph (1) is that the State involved agree 
that the grant will be used to supplement and not supplant 
other funds available to the State to carry out the purposes of 
the grant. 

•Js *J» sfc sfs sfi jfc sfc 

SEC. 2626. PERINATAL TRANSMISSION OF HIV DISEASE; CONTINGENT 
REQUIREMENT REGARDING STATE GRANTS UNDER THIS 
PART. 

( a ) * * * 

******* 

[(d) Determination by Secretary.— Not later than 180 days 
after the expiration of the 18-month period beginning on the date 
on which the system is implemented under subsection (c), the Sec- 
retary shall publish in the Federal Register a determination of 
whether it has become a routine practice in the provision of health 
care in the United States to carry out each of the activities de- 
scribed in paragraphs (1) through (4) of section 2627. In making 
the determination, the Secretary shall consult with the States and 
with other public or private entities that have knowledge or exper- 
tise relevant to the determination. 
[(e) Contingent Applicability. — 

[(1) In GENERAL.— If the determination published in the Fed- 
eral Register under subsection (d) is that (for purposes of such 
subsection) the activities involved have become routine prac- 
tices, paragraph (2) shall apply on and after the expiration of 
the 18-month period beginning on the date on which the deter- 
mination is so published. 

[(2) Requirement.— Subject to subsection (f), the Secretary 
shall not make a grant under part B to a State unless the 
State meets not less than one of the following requirements: 

[(A) A 50 percent reduction (or a comparable measure 
for States with less than 10 cases) in the rate of new cases 
of AIDS (recognizing that AIDS is a suboptimal proxy for 
tracking HIV in infants and was selected because such 
data is universally available) as a result of perinatal trans- 
mission as compared to the rate of such cases reported in 
1993 (a State may use HIV data if such data is available). 

[(B) At least 95 percent of women in the State who have 
received at least two prenatal visits (consultations) prior to 
34 weeks gestation with a health care provider or provider 

HRpt. 106-788 D-00--4 



90 



group have been tested for the human immunodeficiency 
virus. 

[(C) The State has in effect, in statute or through regu- 
lations, the requirements specified in paragraphs (1) 
through (5) of section 2627. 
[(f) Limitation Regarding Availability of Funds.— With re- 
spect to an activity described in any of paragraphs (1) through (4) 
of section 2627, the requirements established by a State under this 
section apply for purposes of this section only to the extent that the 
following sources of funds are available for carrying out the activ- 
ity: 

[(1) Federal funds provided to the State in grants under part 
B or under section 2625, or through other Federal sources 
under which payments for routine HIV testing, counseling or 
treatment are an eligible use. 

[(2) Funds that the State or private entities have elected to 
provide, including through entering into contracts under which 
health benefits are provided. This section does not require any 
entity to expend non-Federal funds. 

[SEC. 2627. TESTING OF PREGNANT WOMEN AND NEWBORN INFANTS. 

[An activity or requirement described in this section is any of 
the following: 

[(1) In the case of newborn infants who are born in the State 
and whose biological mothers have not undergone prenatal 
testing for HIV disease, that each such infant undergo testing 
for such disease. 

[(2) That the results of such testing of a newborn infant be 
promptly disclosed in accordance with the following, as applica- 
ble to the infant involved: 

[(A) To the biological mother of the infant (without re- 
gard to whether she is the legal guardian of the infant). 
[(B) If the State is the legal guardian of the infant: 

[(i) To the appropriate official of the State agency 
with responsibility for the care of the infant. 

[(ii) To the appropriate official of each authorized 
agency providing assistance in the placement of the in- 
fant. 

[(iii) If the authorized agency is giving significant 
consideration to approving an individual as a foster 
parent of the infant, to the prospective foster parent. 

[(iv) If the authorized agency is giving significant 
consideration to approving an individual as an adop- 
tive parent of the infant, to the prospective adoptive 
parent. 

[(C) If neither the biological mother nor the State is the 
legal guardian of the infant, to another legal guardian of 
the infant. 

[(D) To the child's health care provider. 
[(3) That, in the case of prenatal testing for HIV disease 
that is conducted in the State, the results of such testing be 
promptly disclosed to the pregnant woman involved. 

[(4) That, in disclosing the test results to an individual 
under paragraph (2) or (3), appropriate counseling on the 
human immunodeficiency virus be made available to the indi- 



91 



vidual (except in the case of a disclosure to an official of a 
State or an authorized agency). 

[(5) With respect to State insurance laws, that such laws 
require— 

[(A) that, if health insurance is in effect for an indi- 
vidual, the insurer involved may not (without the consent 
of the individual) discontinue the insurance, or alter the 
terms of the insurance (except as provided in subpara- 
graph (C)), solely on the basis that the individual is in- 
fected with HIV disease or solely on the basis that the in- 
dividual has been tested for the disease or its manifesta- 
tion; 

[(B) that subparagraph (A) does not apply to an indi- 
vidual who, in applying for the health insurance involved, 
knowingly misrepresented the HIV status of the indi- 
vidual; and 

[(C) that subparagraph (A) does not apply to any rea- 
sonable alteration in the terms of health insurance for an 
individual with HIV disease that would have been made if 
the individual had a serious disease other than HIV dis- 
ease. 

For purposes of this subparagraph, a statute or regulation 
shall be deemed to regulate insurance for purposes of this 
paragraph only to the extent that such statute or regulation is 
treated as regulating insurance for purposes of section 
514(b)(2) of the Employee Retirement Income Security Act of 
1974.] 

SEC. 2630. RECOMMENDATIONS FOR REDUCING INCIDENCE OF 
PERINATAL TRANSMISSION. 

(a) Study by Institute of Medicine. - 

(1) In GENERAL. — The Secretary shall request the Institute of 
Medicine to enter into an agreement with the Secretary under 
which such Institute conducts a study to provide the following: 

(A) For the most recent fiscal year for which the informa- 
tion is available, a determination of the number of newborn 
infants with HIV born in the United States with respect to 
whom the attending obstetrician for the birth did not know 
the HIV status of the mother. 

(B) A determination for each State of any barriers, in- 
cluding legal barriers, that prevent or discourage an obste- 
trician from making it a routine practice to offer pregnant 
women an HIV test and a routine practice to test newborn 
infants for HIV disease in circumstances in which the ob- 
stetrician does not know the HIV status of the mother of the 
infant. 

(C) Recommendations for each State for reducing the in- 
cidence of cases of the perinatal transmission of HIV, in- 
cluding recommendations on removing the barriers identi- 
fied under subparagraph (B). 

If such Institute declines to conduct the study, the Secretary 
shall enter into an agreement with another appropriate public 
or nonprofit private entity to conduct the study. 



92 

(2) Report. — The Secretary shall ensure that, not later than 
18 months after the effective date of this section, the study re- 
quired in paragraph (1) is completed and a report describing 
the findings made in the study is submitted to the appropriate 
committees of the Congress, the Secretary, and the chief public 
health official of each of the States. 

(b) Progress Toward Recommendations. -Each State shall 
comply with the following ( as applicable to the fiscal year involved): 

(1) For fiscal year 2004, the State shall submit to the Sec- 
retary a report describing the actions taken by the State toward 
meeting the recommendations specified for the State under sub- 
section ( a)( 1)( C). 

(2) For fiscal year 2005 and each subsequent fiscal year— 

(A) the State shall make reasonable progress toward 
meeting such recommendations; or 

(B) if the State has not made such progress — 

(i) the State shall cooperate with the Director of the 
Centers for Disease Control and Prevention in carrying 
out activities toward meeting the recommendations; 
and 

(ii) the State shall submit to the Secretary a report 
containing a description of any barriers identified 
under subsection (a)(1)(B) that continue to exist in the 
State; as applicable, the factors underlying the contin- 
ued existence of such barriers; and a description of how 
the State intends to reduce the incidence of cases of the 
perinatal transmission of HIV. 

(c) Submission of Reports to Congress.— The Secretary shall 
submit to the appropriate committees of the Congress each report re- 
ceived by the Secretary under subsection (b)(2)(B)(ii). 

Subpart III— Certain Partner Notification 
Programs 

SEC. 2631. GRANTS FOR PARTNER NOTIFICATION PROGRAMS. 

(a) In General.— In the case of States whose laws or regulations 
are in accordance with subsection (b), the Secretary, subject to sub- 
section (c)(2), may make grants to the States for carrying out pro- 
grams to provide partner counseling and referral services. 

(b) Description of Compliant State Programs. -For purposes 
of subsection ( a), the laws or regulations of a State are in accord- 
ance with this subsection if under such laws or regulations (includ- 
ing programs carried out pursuant to the discretion of State offi- 
cials) the following policies are in effect: 

(1) The State requires that the public health officer of the 
State carry out a program of partner notification to inform 
partners of individuals with HIV disease that the partners may 
have been exposed to the disease. 

(2) (A) In the case of a health entity that provides for the per- 
formance on an individual of a test for HIV disease, or that 
treats the individual for the disease, the State requires, subject 
to subparagraph (B), that the entity confidentially report the 
positive test results to the State public health officer in a man- 
ner recommended and approved by the Director of the Centers 
for Disease Control and Prevention, together with such addi- 



93 



tional information as may be necessary for carrying out such 
program. 

(B) The State may provide that the requirement of subpara- 
graph (A) does not apply to the testing of an individual for HIV 
disease if the individual underwent the testing through a pro- 
gram designed to perform the test and provide the results to the 
individual without the individual disclosing his or her identity 
to the program. This subparagraph may not be construed as af- 
fecting the requirement of subparagraph (A) with respect to a 
health entity that treats an individual for HIV disease. 

(3) The program under paragraph (1) is carried out in ac- 
cordance with the following: 

(A) Partners are provided with an appropriate oppor- 
tunity to learn that the partners have been exposed to HIV 
disease, subject to subparagraph (B). 

(B) The State does not inform partners of the identity of 
the infected individuals involved. 

(C) Counseling and testing for HIV disease are made 
available to the partners and to infected individuals, and 
such counseling includes information on modes of trans- 
mission for the disease, including information on prenatal 
and perinatal transmission and preventing transmission. 

(D) Counseling of infected individuals and their partners 
includes the provision of information regarding therapeutic 
measures for preventing and treating the deterioration of 
the immune system and conditions arising from the dis- 
ease, and the provision of other prevention-related informa- 
tion. 

(E) Referrals for appropriate services are provided to 
partners and infected individuals, including referrals for 
support services and legal aid. 

(F) Notifications under subparagraph (A) are provided in 
person, unless doing so is an unreasonable burden on the 
State. 

(G) There is no criminal or civil penalty on, or civil li- 
ability for, an infected individual if the individual chooses 
not to identify the partners of the individual, or the indi- 
vidual does not otherwise cooperate with such program. 

(H) The failure of the State to notify partners is not a 
basis for the civil liability of any health entity who under 
the program reported to the State the identity of the in- 
fected individual involved. 

(I) The State provides that the provisions of the program 
may not be construed as prohibiting the State from pro- 
viding a notification under subparagraph (A) without the 
consent of the infected individual involved. 

(4) The State annually reports to the Director of the Centers 
for Disease Control and Prevention the number of individuals 
from whom the names of partners have been sought under the 
program under paragraph ( 1), the number of such individuals 
who provided the names of partners, and the number of part- 
ners so named who were notified under the program. 

(5) The State cooperates with such Director in carrying out a 
national program of partner notification, including the sharing 
of information between the public health officers of the States. 



94 



(c) Reporting System for Cases of HIV Disease. — 

(1) Preference in making grants through fiscal year 
2003.— In making grants under subsection (a) for each of the fis- 
cal years 2001 through 2003, the Secretary shall give preference 
to States whose reporting systems for cases of HIV disease 
produce data on such cases that is sufficiently accurate and re- 
liable for use for purposes of section 2618(b)(2)(D)(i). 

(2) Eligibility condition after fiscal year 2003. —For fis- 
cal year 2004 and subsequent fiscal years, a State may not re- 
ceive a grant under subsection (a) unless the reporting system 
of the State for cases of HIV disease produces data on such 
cases that is sufficiently accurate and reliable for purposes of 
section 2618(b)(2)(D)(i). 

(d) Authorization of Appropriations. -For the purpose of car- 
rying out this section, there are authorized to be appropriated 
$30,000,000 for fiscal year 2001, and such sums as may be nec- 
essary for each of the fiscal years 2002 through 2005. 

Part C— Early Intervention Services 
[Subpart I— Formula Grants for States 
[SEC. 2641. ESTABLISHMENT OF PROGRAM. 

[(a) Allotments for States.— For the purposes described in 
subsection (b), the Secretary, acting through the Director of the 
Centers for Disease Control and Prevention and in consultation 
with the Administrator of the Health Resources and Services Ad- 
ministration, shall for each of the fiscal years 1991 through 1995 
make an allotment for each State in an amount determined in ac- 
cordance with section 2649. The Secretary shall make payments, as 
grants, to each State from the allotment for the State for the fiscal 
year involved if the Secretary approves for the fiscal year an appli- 
cation submitted by the State pursuant to section 2665. 
[(b) Purposes of Grants.— 

[(1) In general.— The Secretary may not make a grant 
under subsection (a) unless the State involved agrees to expend 
the grant for the purposes of providing, on an outpatient basis, 
each of the early intervention services specified in paragraph 
(2) with respect to HIV disease. 

[(2) Specification of early intervention services.— The 
early intervention services referred to in paragraph (1) are— 
[(A) counseling individuals with respect to HIV disease 
in accordance with section 2662; 

[(B) testing individuals with respect to such disease, in- 
cluding tests to confirm the presence of the disease, tests 
to diagnose the extent of the deficiency in the immune sys- 
tem, and tests to provide information on appropriate 
therapeutic measures for preventing and treating the dete- 
rioration of the immune system and for preventing and 
treating conditions arising from the disease; 
[(C) referrals described in paragraph (3); 
[(D) other clinical and diagnostic services with respect to 
HIV disease, and periodic medical evaluations of individ- 
uals with the disease; and 



95 



[(E) providing the therapeutic measures described in 
subparagraph (B). 
[(3) Referrals.— The services referred to in paragraph 
(2XC) are referrals of individuals with HIV disease to appro- 
priate providers of health and support services, including, as 
appropriate— 

(A) to entities receiving amounts under part A or B for 
the provision of such services; 

[(B) to biomedical research facilities of institutions of 
higher education that offer experimental treatment for 
such disease, or to community-based organizations or other 
entities that provide such treatment; or 

[(C) to grantees under section 2671, in the case of preg- 
nant women. 

[(4) Requirement of availability of all early interven- 
tion SERVICES THROUGH EACH GRANTEE.— The Secretary may 
not make a grant under subsection (a) unless the State in- 
volved agrees that each of the early intervention services speci- 
fied in paragraph (2) will be available through the State. With 
respect to compliance with such agreement, a State may ex- 
pend the grant to provide the early intervention services di- 
rectly, and may expend the grant to enter into agreements 
with public or nonprofit private entities under which the enti- 
ties provide the services. 

[(5) Optional services.— A State receiving a grant under 
subsection (a)— 

[(A) may expend not more than 5 percent of the grant 
to provide early intervention services through making 
grants to hospitals that— 

[(i) for the most recent fiscal year for which the 
data is available, have admitted— 

[(I) not fewer than 250 individuals with ac- 
quired immune deficiency syndrome; or 

[(II) a number of such individuals constituting 
20 percent of the number of inpatients of the hos- 
pital admitted during such period; 
[(ii) agree to offer and encourage such services with 
respect to inpatients of the hospitals; and 

[(iii) agree that subsections (c) and (d) of section 
2644 will apply to the hospitals to the same extent 
and in the same manner as such subsections apply to 
entities described in such section; 
[(B) may expend the grant to provide outreach services 
to individuals who may have HIV disease, or may be at 
risk of the disease, and who may be unaware of the avail- 
ability and potential benefits of early treatment of the dis- 
ease, and to provide outreach services to health care pro- 
fessionals who may be unaware of such availability and 
potential benefits; and 

[(C) may, in the case of individuals who seek early inter- 
vention services from the grantee, expend the grant— 

[(i) for case management to provide coordination in 
the provision of health care services to the individuals 
and to review the extent of utilization of the services 
by the individuals; and 



96 



[(ii) to provide assistance to the individuals regard- 
ing establishing the eligibility of the individuals for fi- 
nancial assistance and services under Federal, State, 
or local programs providing for health services, mental 
health services, social services, or other appropriate 
services. 
[(6) Allocations.— 

[(A) Subject to subparagraphs (B) and (C), the Secretary 
may not make a grant under subsection (a) unless the 
State involved agrees— 

[(i) to expend not less than 35 percent of the grant 
to provide the early intervention services specified in 
subparagraphs (A) through (C) of paragraph (2); and 
[(ii) to expend not less than 35 percent of the grant 
to provide the early intervention services specified in 
subparagraphs (D) and (E) of such paragraph. 
[(B) With respect to compliance with the agreement 
under subparagraph (A), amounts reserved by a State for 
fiscal year 1991 for purposes of clauses (i) and (ii) of such 
subparagraph may be expended to provide the services 
specified in paragraph (5). 

[(C) The Secretary shall ensure that, of the amounts ap- 
propriated under section 2650 for fiscal year 1991, an 
amount equal to $130,000,000 is expended to provide the 
early intervention services specified in subparagraphs (A) 
through (C) of paragraph (2). 

[SEC. 2642. PROVISION OF SERVICES THROUGH MEDICAID PRO- 
VIDERS. 

[(a) In General.— Subject to subsection (b), the Secretary may 
not make a grant under section 2641 to a State unless, in the case 
of any service described in subsection (b) of such section that is 
available pursuant to the State plan approved under title XLX of 
the Social Security Act for the State— 

[(1) the State will provide the service through a State entity, 
and the State entity has entered into a participation agree- 
ment under the State plan and is qualified to receive payments 
under such plan; or 

[(2) the State will enter into an agreement with a public or 
nonprofit private entity under which the entity will provide the 
service, and the entity has entered into such a participation 
agreement and is qualified to receive such payments. 
[(b) Waiver Regarding Certain Secondary Agreements.— 
[(1) In general.— In the case of an entity making an agree- 
ment pursuant to subsection (a)(2) regarding the provision of 
services, the requirement established in such subsection re- 
garding a participation agreement shall be waived by the Sec- 
retary if the entity does not, in providing health care services, 
impose a charge or accept reimbursement available from any 
third-party payor, including reimbursement under any insur- 
ance policy or under any Federal or State health benefits pro- 
gram. 

[(2) Acceptance of voluntary donations.— A determina- 
tion by the Secretary of whether an entity referred to in para- 
graph (1) meets the criteria for a waiver under such subpara- 
graph shall be made without regard to whether the entity ac- 



97 

cepts voluntary donations for the purpose of providing services 
to the public. 

[SEC. 2643. REQUIREMENT OF MATCHING FUNDS. 

[(a) In General.— In the case of any State to which the criterion 
described in subsection (c) applies, the Secretary may not make a 
grant under section 2641 unless the State agrees that, with respect 
to the costs to be incurred by the State in carrying out the purpose 
referred to in such subsection, the State will, subject to subsection 
(b)(2), make available (directly or through donations from public or 
private entities) non-Federal contributions toward such costs in an 
amount equal to— 

[(1) for the first fiscal year for which such criterion applies 

to the State, not less than 16% percent of such costs ($1 for 

each $5 of Federal funds provided in the grant); 

[(2) for any second such fiscal year, not less than 20 percent 

of such costs ($1 for each $4 of Federal funds provided in the 

grant); 

[(3) for any third such fiscal year, not less than 25 percent 
of such costs ($1 for each $3 of Federal funds provided in the 
grant); and 

[(4) for any subsequent fiscal year, not less than 33 Vs per- 
cent of such costs ($1 for each $2 of Federal funds provided in 
the grant). 

[(b) Determination of Amount of Non-Federal Contribu- 
tion.— 

[(1) In general.— Non-Federal contributions required in 
subsection (a) may be in cash or in kind, fairly evaluated, in- 
cluding plant, equipment, or services. Amounts provided by the 
Federal Government, and any portion of any service subsidized 
by the Federal Government, may not be included in deter- 
mining the amount of such non-Federal contributions. 
[(2) Inclusion of certain amounts.— 

[(A) In making a determination of the amount of non- 
Federal contributions made by a State for purposes of sub- 
section (a), the Secretary shall, subject to subparagraph 
(B), include any non-Federal contributions provided by the 
State for HIV-related services, without regard to whether 
the contributions are made for programs established pur- 
suant to this title. 

[(B) In making a determination for purposes of subpara- 
graph (A), the Secretary may not include any non-Federal 
contributions provided by the State as a condition of re- 
ceiving Federal funds under any program under this title 
(except for the program established in section 2641) or 
under other provisions of law. 
[(c) Applicability of Matching Requirement.— 

[(1) Percentage of national number of cases.— 

[(A) The criterion referred to in subsection (a) is, with 
respect to a State, that the number of cases of acquired 
immune deficiency syndrome reported to and confirmed by 
the Director of the Centers for Disease Control and Pre- 
vention for the State for the period described in subpara- 
graph (B) constitutes more than 1 percent of the number 
of such cases reported to and confirmed by the Director for 
the United States for such period. 



98 



[(B) The period referred to in subparagraph (A) is the 2- 
year period preceding the fiscal year for which the State 
involved is applying to receive a grant under section 2641. 
[(2) Exemption.— For purposes of paragraph (1), the number 
of cases of acquired immune deficiency syndrome reported and 
confirmed for the Commonwealth of Puerto Rico for any fiscal 
year shall be deemed to be less than 1 percent. 
[(d) Diminished State Contribution.— With respect to a State 
that does not make available the entire amount of the non-Federal 
contribution referred to in subsection (a), the State shall continue 
to be eligible to receive Federal funds under a grant under section 
2641, except that the Secretary in providing Federal funds under 
the grant shall provide such funds (in accordance with the ratios 
prescribed in paragraph (1)) only with respect to the amount of 
funds contributed by such State. 

[SEC. 2644. OFFERING AND ENCOURAGING EARLY INTERVENTION 
SERVICES. 

[(a) In General.— The Secretary may not make a grant under 
section 2641 unless, in the case of entities to which the State pro- 
vides amounts from the grant for the provision of early interven- 
tion services, the State involved agrees that— 

[(1) if the entity is a health care provider that regularly pro- 
vides treatment for sexually transmitted diseases, the entity 
will offer and encourage such services with respect to individ- 
uals to whom the entity provides such treatment; 

[(2) if the entity is a health care provider that regularly pro- 
vides treatment for intravenous substance abuse, the entity 
will offer and encourage such services with respect to individ- 
uals to whom the entity provides such treatment; 

[(3) if the entity is a family planning clinic, the entity will 
offer and encourage such services with respect to individuals to 
whom the entity provides family planning services and whom 
the entity has reason to believe has HIV disease; and 

[(4) if the entity is a health care provider that provides 
treatment for tuberculosis, the entity will offer and encourage 
such services with respect to individuals to whom the entity 
provides such treatment. 
[(b) Sufficiency of Amount of Grant.— With respect to com- 
pliance with the agreement made under subsection (a), an entity to 
which subsection (a) applies may be required to offer, encourage, 
and provide early intervention services only to the extent that the 
amount of the grant is sufficient to pay the costs of offering, en- 
couraging, and providing the services. 

[(c) Criteria for Offering and Encouraging.— Subject to sec- 
tion 2641(b)(4), an entity to which subsection (a) applies is, for pur- 
poses of such subsection, offering and encouraging early interven- 
tion services with respect to the individuals involved if the entity— 
[(1) offers such services to the individuals, and encourages 
the individuals to receive the services, as a regular practice in 
the course of providing the health care involved; and 

[(2) provides the early intervention services only with the 
consent of the individuals. 



99 



[SEC. 2645. NOTIFICATION OF CERTAIN INDIVIDUALS RECEIVING 
BLOOD TRANSFUSIONS. 

[(a) In General.— The Secretary may not make a grant under 
section 2641 unless the State involved provides assurances satisfac- 
tory to the Secretary that, with respect to individuals in the State 
receiving, between January 1, 1978, and April 1, 1985 (inclusive), 
a transfusion of whole blood or a blood-clotting factor, the State 
will provide public education and information for the purpose of— 
[(1) encouraging the population of such individuals to receive 
early intervention services; and 

[(2) informing such population of any health facilities in the 
geographic area involved that provide such services. 
[(b) Rule of Construction.— An agreement made under sub- 
section (a) may not be construed to require that, in carrying out the 
activities described in such subsection, a State receiving a grant 
under section 2641 provide individual notifications to the individ- 
uals described in such subsection. 

[SEC. 2646. REPORTING AND PARTNER NOTIFICATION. 

[(a) Reporting.— The Secretary may not make a grant under 
section 2641 unless, with respect to testing for HIV disease, the 
State involved provides assurances satisfactory to the Secretary 
that the State will require that any entity carrying out such testing 
confidentially report to the State public health officer information 
sufficient— 

[(1) to perform statistical and epidemiological analyses of the 
incidence in the State of cases of such disease; 

[(2) to perform statistical and epidemiological analyses of the 
demographic characteristics of the population of individuals in 
the State who have the disease; and 

[(3) to assess the adequacy of early intervention services in 
the State. 

[(b) Partner Notification.— The Secretary may not make a 
grant under section 2641 unless the State involved provides assur- 
ances satisfactory to the Secretary that the State will require that 
the public health officer of the State, to the extent appropriate in 
the determination of the officer, carry out a program of partner no- 
tification regarding cases of HIV disease. 

[(c) Rules of Construction.— An agreement made under this 
section may not be construed— 

[(1) to require or prohibit any State from providing that 
identifying information concerning individuals with HIV dis- 
ease is required to be submitted to the State; or 

[(2) to require any State to establish a requirement that en- 
tities other than the public health officer of the State are re- 
quired to make the notifications referred to in subsection (b). 

[SEC. 2647. REQUIREMENT OF STATE LAW PROTECTION AGAINST IN- 
TENTIONAL TRANSMISSION, 
[(a) In General.— The Secretary may not make a grant under 
section 2641 to a State unless the chief executive officer determines 
that the criminal laws of the State are adequate to prosecute any 
HIV infected individual, subject to the condition described in sub- 
section (b), who— 

[(1) makes a donation of blood, semen, or breast milk, if the 
individual knows that he or she is infected with HIV and in- 



100 



tends, through such donation, to expose another HIV in the 
event that the donation is utilized; 

[(2) engages in sexual activity if the individual knows that 
he or she is infected with HIV and intends, through such sex- 
ual activity, to expose another to HIV; and 

[(3) injects himself or herself with a hypodermic needle and 
subsequently provides the needle to another person for pur- 
poses of hypodermic injection, if the individual knows that he 
or she is infected and intends, through the provision of the 
needle, to expose another to such etiologic agent in the event 
that the needle is utilized. 
[(b) Consent to Risk of Transmission.— The State laws de- 
scribed in subsection (a) need not apply to circumstances under 
which the conduct described in paragraphs (1) through (3) of sub- 
section (a) if the individual who is subjected to the behavior in- 
volved knows that the other individual is infected and provides 
prior informed consent to the activity. 

[(c) State Certification With Respect to Required Laws.— 
With respect to complying with subsection (a) as a condition of re- 
ceiving a grant under section 2641, the Secretary may not require 
a State to enact any statute, or to issue any regulation, if the chief 
executive officer of the State certifies to the Secretary that the laws 
of the State are adequate. The existence of a criminal law of gen- 
eral application, which can be applied to the conduct described in 
paragraphs (1) through (3) of subsection (a), is sufficient for compli- 
ance with this section. 

[(d) Time Limitations With Respect to Required Laws.— With 
respect to receiving a grant under section 2641, if a State is unable 
to certify compliance with subsection (a), the Secretary may make 
a grant to a State under such section if— 

[(1) for each of the fiscal years 1991 and 1992, the State pro- 
vides assurances satisfactory to the Secretary that by not later 
than October 1, 1992, the State will have in place or will estab- 
lish the prohibitions described in subsection (a); and 

[(2) for fiscal year 1993 and subsequent fiscal years, the 
State has established such prohibitions. 

[SEC. 2648. TESTING AND OTHER EARLY INTERVENTION SERVICES 
FOR STATE PRISONERS. 

[(a) In General.— In addition to grants under section 2641, the 
Secretary may make grants to States for the purpose of assisting 
the States in providing early intervention services to individuals 
sentenced by the State to a term of imprisonment. The Secretary 
may make such a grant only if the State involved requires, subject 
to subsection (d), that— 

[(1) the services be provided to such individuals; and 
[(2) each such individual be informed of the requirements of 
subsection (c) regarding testing and be informed of the results 
of such testing of the individual. 
[(b) Requirement of Matching Funds.— 

[(1) In general.— The Secretary may not make a grant 
under subsection (a) unless the State involved agrees that, 
with respect to the costs to be incurred by the State in carrying 
out the purpose described in such subsection, the State will 
make available (directly or through donations from public or 



101 



private entities) non-Federal contributions toward such costs in 
an amount equal to— 

[(A) for the first fiscal year of payments under the 
grant, not less than $1 for each $2 of Federal funds pro- 
vided in the grant; and 

[(B) for any subsequent fiscal year of such payments, 
not less than $1 for each $1 of Federal funds provided in 
the grant. 

[(2) Determination of amount of non-federal contribu- 
tion.— Non-Federal contributions required in paragraph (1) 
may be in cash or in kind, fairly evaluated, including plant, 
equipment, or services. Amounts provided by the Federal Gov- 
ernment, and services (or portions of services) subsidized by 
the Federal Government, may not be included in determining 
the amount of such non-Federal contributions. 
[(c) Testing.— The Secretary may not make a grant under sub- 
section (a) unless— 

[(1) the State involved requires that, subject to subsection 
(d), any individual sentenced by the State to a term of impris- 
onment be tested for HIV disease— 

[(A) upon entering the State penal system; and 
[(B) during the 30-day period preceding the date on 
which the individual is released from such system; 
[(2) with respect to informing employees of the penal system 
of the results of such testing of the individual, the State— 

[(A) upon the request of any such employee, provides 
the results to the employee in any case in which the med- 
ical officer of the prison determines that there is a reason- 
able basis for believing that the employee has been ex- 
posed by the individual to such disease; and 

[(B) informs the employees of the availability to the em- 
ployees of such results under the conditions described in 
subparagraph (A); 
[(3) with respect to informing the spouse of the individual of 
the results of such testing of the individual, the State— 

[(A) upon the request of the spouse, provides such re- 
sults to the spouse prior to any conjugal visit and provides 
such results to the spouse during the period described in 
paragraph (1XB); and 

[(B) informs the spouse of the availability to the spouse 
of such results under the conditions described in subpara- 
graph (A); 

[(4) with respect to such testing upon entering the State 
penal system of such an individual who has been convicted of 
rape or aggravated sexual assault, the State— 

[(A) upon the request of the victim of the rape or as- 
sault, provides such results to the victim; and 

[(B) informs the victim of the availability to the victim 
of such results; and 
[(5) the State, except as provided in any of paragraphs (2) 
through (4), maintains the confidentiality of the results of test- 
ing for HIV disease in each prison operated by the State or 
with amounts provided by the State, and makes disclosures of 
such results only as medically necessary. 
[(d) Determination of Prisons Subject to Requirement.— 



102 

[(1) In general.— The Secretary may not make a grant 
under subsection (a) unless the State involved agrees that the 
requirement established in such subsection regarding the pro- 
vision of early intervention services to inmates will apply only 
to inmates who are incarcerated in prisons with respect to 
which the State public health officer, after consultation with 
the chief State correctional officer, has, on the basis of the cri- 
teria described in paragraph (2), determined that the provision 
of such services is appropriate with respect to the public health 
and safety. 

[(2) Description of criteria.— The criteria to be considered 
for purposes of paragraph (1) are— 

((A) with respect to the geographic areas in which in- 
mates of the prison involved resided before incarceration 
in the prison— 

t(i) the severity of the epidemic of HIV disease in 
the areas during the period in which the inmates re- 
sided in the areas; and 

[(h) the incidence, in the areas during such period, 
of behavior that places individuals at significant risk 
of developing HIV disease; and 
[(B) the extent to which medical examinations conducted 
by the State for inmates of the prison involved indicate 
that the inmates have engaged in such behavior. 
[(e) Applicability of Provisions Regarding Informed Con- 
sent, Counseling, and Other Matters.— The Secretary may not 
make a grant under subsection (a) unless the State involved agrees 
that sections 2641(b)(4), 2662, and 2664(c) will apply to the provi- 
sion of early intervention services pursuant to the grant in the 
same manner and to the same extent as such sections apply to the 
provision of such services by grantees under section 2641. 

[(f) Requirement of Application.— The Secretary may not 
make a grant under subsection (a) unless an application for the 
grant is submitted to the Secretary and the application is in such 
form, is made in such manner, and contains such agreements, as- 
surances, and information as the Secretary determines to be nec- 
essary to carry out this section. 

[(g) Rule of Construction.— With respect to testing inmates of 
State prisons for HIV disease without the consent of the inmates, 
the agreements made under this section may not be construed to 
authorize, prohibit, or require any State to conduct such testing, 
except as provided in subparagraphs (A) and (B) of subsection 
(0(1). 

[(h) Authorization of Appropriations.— To carry out this sec- 
tion, there are authorized to be appropriated such sums as may be 
necessary for each of the fiscal years 1988 through 1995. 

[SEC. 2649. DETERMINATION OF AMOUNT OF ALLOTMENTS. 

[(a) Minimum Allotment.— Subject to the extent of amounts 
made available in appropriations Acts, the amount of an allotment 
under section 2641(a) for a State for a fiscal year shall be the 
greater of— 

[(1) $100,000 for each of the several States, the District of 
Columbia, and the Commonwealth of Puerto Rico, and $50,000 
for each of the territories of the United States other than the 
Commonwealth of Puerto Rico; and 



103 



[(2) an amount determined under subsection (b). 
[(b) Determination Under Formula.— The amount referred to 
subsection (aX2) is the product of— 

[(1) an amount equal to the amount appropriated under sec- 
tion 2650 for the fiscal year involved; and 
[(2) a percentage equal to the quotient of— 

[(A) an amount equal to the number of cases of acquired 
immune deficiency syndrome reported to and confirmed by 
the Director of the Centers for Disease Control and Pre- 
vention for the State involved for the most recent fiscal 
year for which such data is available; divided by 

[(B) an amount equal to the number of cases of acquired 
immune deficiency syndrome reported to and confirmed by 
the Director of the Centers for Disease Control and Pre- 
vention for the United States for the most recent fiscal 
year for which such data is available. 
[(c) Certain Allocations by Secretary.— 

[(1) Discretionary grants to certain states.— After de- 
termining the amount of an allotment under subsection (a) for 
a fiscal year, the Secretary shall reduce the amount of the al- 
lotment of each State by 10 percent. From the amounts avail- 
able as a result of such reductions, the Secretary shall, on a 
discretionary basis, make grants to States receiving allotments 
for the fiscal year involved. Such grants shall be made subject 
to each of the agreements and assurances required as a condi- 
tion of receiving grants under section 2641. 
[(2) Grants to certain political subdivisions.— 

[(A)(i) In the case of a State containing any political 
subdivision described in clause (ii), the Secretary shall, 
subject to subparagraph (B), make a reduction in the 
amount of the allotment under subsection (a) for the State 
for each fiscal year in an amount necessary for carrying 
out subparagraphs (B) and (C) with respect to the political 
subdivision. Any such reduction shall be in addition to the 
reduction required in paragraph (1) for the fiscal year in- 
volved. 

[(ii) The political subdivision referred to in clause (i) is 
any political subdivision that received a cooperative agree- 
ment from the Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, for fiscal 
year 1990 for programs to provide counseling and testing 
with respect to acquired immune deficiency syndrome. 

[(B) In the case of a State described in subparagraph 
(A), the Secretary shall, from the amounts made available 
as a result of reductions under such subparagraph, make 
a grant each fiscal year to each political subdivision de- 
scribed in such subparagraph that exists in the State if the 
political subdivision involved agrees that the provisions of 
subparts II and III will apply to the political subdivision 
to the same extent and in the same manner as such sub- 
parts apply to entities receiving grants under section 
2651(a). 

[(C) Grants under subparagraph (B) for a fiscal year for 
a political subdivision shall be provided in an amount 
equal to the amount received by the political subdivision 



104 

in fiscal year 1990 under the cooperative agreement de- 
scribed in subparagraph (A). 
[(d) Disposition of Certain Funds Appropriated for Allot- 
ments.— 

[(1) In general.— Any amounts available pursuant to para- 
graph (2) shall, in accordance with paragraph (3), be allotted 
by the Secretary each fiscal year to States receiving payments 
under section 2641(a) for the fiscal year (other than any State 
referred to in paragraph (2)(C)). The Secretary shall make pay- 
ments, as grants, to each such State from any such allotment 
for the State for the fiscal year involved. 

[(2) Specification of amounts.— The amounts referred to 
in paragraph (1) are any amounts that are not paid to States 
under section 2641(a) as a result of— 

[(A) the failure of any State to submit an application 
under section 2651; 

[(B) the failure, in the determination of the Secretary, 
of any State to prepare the application in compliance with 
such section or to submit the application within a reason- 
able period of time; or 

[(C) any State informing the Secretary that the State 
does not intend to expend the full amount of the allotment 
made to the State. 
[(3) Amount of allotment.— The amount of an allotment 
under paragraph (1) for a State for a fiscal year shall be an 
amount equal to the product of— 

[(A) an amount equal to the amount available pursuant 
to paragraph (2) for the fiscal year involved; and 

[(B) the percentage determined under subsection (b)(2) 
for the State. 
[(e) Transition Rules.— 

[(1) For the fiscal years 1991 through 1993, the amount of 
an allotment under section 2641 shall be the greater of the 
amount determined under subsection (a) and an amount equal 
to the amount applicable under paragraph (2) for the fiscal 
year involved. 

[(2) For purposes of paragraph (1)— 

[(A) the amount applicable for fiscal year 1991 is an 
amount equal to the amount received by the State involved 
from the Secretary, acting through the Director of the Cen- 
ters for Disease Control and Prevention, for fiscal year 
1990 for the provision of counseling and testing services 
with respect to HIV; 

[(B) the amount applicable for fiscal year 1992 is 85 per- 
cent of the amount specified in subparagraph (A); and 

[(C) the amount applicable for fiscal year 1993 is 70 per- 
cent of the amount specified in subparagraph (A). 

[SEC. 2649A. MISCELLANEOUS PROVISIONS. 

[The Secretary may not make a grant under section 2641 
unless— 

[(1) the State involved submits to the Secretary a com- 
prehensive plan for the organization and delivery of the early 
intervention services to be funded with the grant that includes 
a description of the purposes for which the State intends to use 
such assistance, including— 



105 



[(A) the services and activities to be provided and an ex- 
planation of the manner in which the elements of the pro- 
gram to be implemented by the State with the grant will 
maximize the quality of early intervention services avail- 
able to individuals with HIV disease throughout the State; 
and 

[(B) a description of the manner in which services fund- 
ed with the grant will be coordinated with other available 
related services for individuals with HIV disease; and 
[(2) the State agrees that— 

[(A) the public health agency administering the grant 
will conduct public hearings regarding the proposed use 
and distribution of the grant; 

[(B) to the maximum extent practicable, early interven- 
tion services delivered pursuant to the grant will be pro- 
vided without regard to the ability of the individual to pay 
for such services and without regard to the current or past 
health condition of the individual with HIV disease; 

[(C) early intervention services under the grant will be 
provided in settings accessible to low-income individuals 
with HIV disease; and 

[(D) outreach to low-income individuals with HIV dis- 
ease will be provided to inform such individuals of the 
services available pursuant to the grant. 

[SEC. 2650. AUTHORIZATION OF APPROPRIATIONS. 

For the purpose of making grants under section 2641, there are 
authorized to be appropriated $230,000,000 for fiscal year 1991, 
and such sums as may be necessary for each of the fiscal years 
1992 through 1995. 

******* 

Subpart II— Categorical Grants 

******* 

SEC. 2653. PREFERENCES IN MAKING GRANTS. 

(a) * * * 

******* 

(d) Underserved and Rural Areas. — Of the applicants who 
qualify for preference under this section, the Secretary shall give 
preference to applicants that will expend the grant under section 
2651 to provide early intervention under such section in rural areas 
or in areas that are underserved with respect to such services. 

SEC. 2654. MISCELLANEOUS PROVISIONS. 

( a ) * * * 

******* 

(c) Planning and Development Grants.— 

(1) In general.— The Secretary may provide [planning 
grants, in an amount not to exceed $50,000 for each such 
grant, to public and nonprofit private entities for the purpose 
of enabling such entities to provide HIV early intervention 
services.] planning grants to public and nonprofit private enti- 
ties for purposes of— 



106 



(A) enabling such entities to provide HIV early interven- 
tion services; and 

(B) assisting the entities in expanding their capacity to 
provide HIV-related health services, including early inter- 
vention services, in low-income communities and affected 
subpopulations that are underserved with respect to such 
services (subject to the condition that a grant pursuant to 
this subparagraph may not be expended to purchase or im- 
prove land, or to purchase, construct, or permanently im- 
prove, other than minor remodeling, any building or other 
facility). 

(4) Amount and duration of grants. - 

(A) Early intervention services. -A grant under 
paragraph (1)(A) may be made in an amount not to exceed 
$50,000. 

(B) Capacity development. - 

(i) Amount.— A grant under paragraph (1)(B) may 
be made in an amount not to exceed $150,000. 

(ii) Duration — The total duration of a grant under 
paragraph (1)(B), including any renewal, may not ex- 
ceed 3 years. 

[(4)] (5) Limitation.— Not to exceed [1] 5 percent of the 
amount appropriated for a fiscal year under section 2655 may 
be used to carry out this section. 

SEC. 2655. AUTHORIZATION OF APPROPRIATIONS. 

For the purpose of making grants under section 2651, there are 
authorized to be appropriated such sums as may be necessary [in 
each of the fiscal years 1996, 1997, 1998, 1999, and 2000.] for each 
of the fiscal years 2001 through 2005. 

Subpart III— General Provisions 

SEC. 2662. PROVISION OF CERTAIN COUNSELING SERVICES. 

(a) * * * 

(c) Counseling of Individuals With Positive Test Results.— 
The Secretary may not make a grant under this part unless the ap- 
plicant for the grant agrees that, if the results of testing for HIV 
disease indicate that the individual has the disease, the applicant 
will provide to the individual appropriate counseling regarding 

such disease, including— 

^ * * * 

(3) providing counseling [on] — 

(A) on the availability, through the applicant, of early 
intervention services; 

(B) on the availability in the geographic area of appro- 
priate health care, mental health care, and social and sup- 
port services, including providing referrals for such serv- 
ices, as appropriate; 



107 



[(C) the benefits] (C)(i) that explains the benefits of lo- 
cating and counseling any individual by whom the infected 
individual may have been exposed to HIV and any indi- 
vidual whom the infected individual may have exposed to 
HIV; and 

(ii) that emphasizes it is the duty of infected individuals 
to disclose their infected status to their sexual partners and 
their partners in the sharing of hypodermic needles; that 
provides advice to infected individuals on the manner in 
which such disclosures can be made; and that emphasizes 
that it is the continuing duty of the individuals to avoid 
any behaviors that will expose others to HIV; 

(D) on the availability of the services of public health au- 
thorities with respect to locating and counseling any indi- 
vidual described in subparagraph (C). 

:fs * * # * * * 

SEC. 2664. ADDITIONAL REQUIRED AGREEMENTS. 

(a) * * * 

£ ♦ % ■ %f :£ 

(g) Administration of Grant.— The Secretary may not make a 
grant under this part unless the applicant for the grant agrees 
that- 

^ * * * 

£ 3fc :£ :£ :£ :£ :£ 

(3) the applicant will not expend more than [7.5] 10 percent 
including planning and evaluation of the grant for administra- 
tive expenses with respect to the grant; [and] 

(4) the applicant will submit evidence that the proposed pro- 
gram is consistent with the statewide coordinated statement of 
need and agree to participate in the ongoing revision of such 
statement of need [. J; and 

(5) the applicant will provide for the establishment of a qual- 
ity management program to assess the extent to which medical 
services funded under this title that are provided to patients are 
consistent with the most recent Public Health Service guidelines 
for the treatment of HIV disease and related opportunistic infec- 
tions and that improvements in the access to and quality of 
medical services are addressed. 

Part D— General Provisions 

SEC. 2671. GRANTS FOR COORDINATED SERVICES AND ACCESS TO RE- 
SEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH. 

(a) * * * 

(b) Provisions Regarding Participation in Research.— 

(1) In general.— With respect to the projects of research 
with which an applicant under subsection (a) is concerned, the 
Secretary may make a grant under such subsection to the ap- 
plicant only if the following conditions are met: 
(A) * * * 



108 



[(C) For the first and second fiscal years for which 
grants under subsection (a) are to be made to the appli- 
cant, the applicant agrees that, not later than the end of 
the second fiscal year of receiving such a grant, a signifi- 
cant number of women, infants, children, and youth who 
are patients of the applicant will be participating in the 
projects of research. 

[(D) Except as provided in paragraph (3) (and paragraph 
(4), as applicable), for the third and subsequent fiscal 
years for which such grants are to be made to the appli- 
cant, the Secretary has determined that a significant num- 
ber of such individuals are participating in the projects.] 

(C) The applicant will demonstrate linkages to research 
and how access to such research is being offered to patients. 

Hs * * sfc * sf! * 

[(3) Significant participation; consideration by sec- 
retary of certain circumstances.— In administering the re- 
quirement of paragraph (1)(D), the Secretary shall take into ac- 
count circumstances in which a grantee under subsection (a) is 
temporarily unable to comply with the requirement for reasons 
beyond the control of the grantee, and shall in such cir- 
cumstances provide to the grantee a reasonable period of op- 
portunity in which to reestablish compliance with the require- 
ment. 

[(4) Significant participation; temporary waiver for 
original grantees.— 

[(A) In general.— In the case of an applicant under 
subsection (a) who received a grant under such subsection 
for fiscal year 1995, the Secretary may, subject to subpara- 
graph (B), provide to the applicant a waiver of the require- 
ment of paragraph (1)(D) if the Secretary determines that 
the applicant is making reasonable progress toward meet- 
ing the requirement. 

[(B) Termination of authority for waivers.— The 
Secretary may not provide any waiver under subparagraph 
(A) on or after October 1, 1998. Any such waiver provided 
prior to such date terminates on such date, or on such ear- 
lier date as the Secretary may specify.] 
[(f) Application.— ] 

(f) Administration. - 

(1) Application.— A grant under subsection (a) may be made 
only if an application for the grant is submitted to the Sec- 
retary and the application is in such form, is made in such 
manner, and contains such agreements, assurances, and infor- 
mation as the Secretary determines to be necessary to carry 
out this section. 

(2) Quality management program.— A grantee under this 
section shall implement a quality management program. 

(g) Coordination With National Institutes of Health.— The 
Secretary shall develop and implement a plan that provides for the 
coordination of the activities of the National Institutes of Health 
with the activities carried out under this section. In carrying out 
the preceding sentence, the Secretary shall ensure that projects of 
research conducted or supported by such Institutes are made aware 
of applicants and grantees under subsection (a), shall require that 



109 



the projects, as appropriate, enter into arrangements for purposes 
of such subsection, and shall require that each project entering into 
such an arrangement inform the applicant or grantee under such 
subsection of the needs of the project for the participation of 
women, infants, children, and youth. In addition, the Secretary, in 
coordination with the Director of such Institutes, shall examine the 
distribution and availability of appropriate HIV-related research 
projects with respect to grantees under subsection (a) for purposes 
of enhancing and expanding HIV-related research, especially within 
communities that are underrepresented with respect to such projects. 

(j) Authorization of Appropriations.— For the purpose of car- 
rying out this section, there are authorized to be appropriated such 
sums as may be necessary for each of the fiscal years [1996 
through 2000] 2001 through 2005. 

******* 

SEC. 2674. EVALUATIONS AND REPORTS. 

(a) * * * 

******* 

(c) Authorization of Appropriations.— There are authorized to 
be appropriated to carry out this section, such sums as may be nec- 
essary for each of the fiscal years [1991 through 1995] 2001 
through 2005. 

■jC ; Sf* ; 5{C Sfw •{» *(* 3ffi 

SEC. 2675. DATA COLLECTION. 

For the purpose of collecting and providing data for program 
planning and evaluation activities under this title, there are author- 
ized to be appropriated to the Secretary (acting through the Director 
of the Centers for Disease Control and Prevention) such sums as 
may be necessary for each of the fiscal years 2001 through 2005. 
Such authorization of appropriations is in addition to other author- 
izations of appropriations that are available for such purpose. 

SEC. [2675] 2675A. COORDINATION. 

[(a) Requirement.— The Secretary shall assure that the Health 
Resources and Services Administration and the Centers for Disease 
Control and Prevention will coordinate the planning of the funding 
of programs authorized under this title to assure that health sup- 
port services for individuals with HIV disease are integrated with 
each other and that the continuity of care of individuals with HIV 
disease is enhanced. In coordinating the allocation of funds made 
available under this title the Health Resources and Services Ad- 
ministration and the Centers for Disease Control and Prevention 
shall utilize planning information submitted to such agencies by 
the States and entities eligible for support.] 

(a) Requirement. -The Secretary shall ensure that the Health 
Resources and Services Administration, the Centers for Disease 
Control and Prevention, the Substance Abuse and Mental Health 
Services Administration, and the Health Care Financing Adminis- 
tration coordinate the planning, funding, and implementation of 
Federal HIV programs to enhance the continuity of care and preven- 
tion services for individuals with HIV disease or those at risk of 
such disease. The Secretary shall consult with other Federal agen- 



110 



ties, including the Department of Veterans Affairs, as needed and 
utilize planning information submitted to such agencies by the 
States and entities eligible for support. 

(b) Report. — The Secretary shall biennially prepare and submit 
to the appropriate committees of the Congress a report concerning 
the coordination efforts at the Federal, State, and local levels de- 
scribed in this section, including a description of Federal barriers 
to HIV program integration and a strategy for eliminating such 
barriers and enhancing the continuity of care and prevention serv- 
ices for individuals with HIV disease or those at risk of such dis- 
ease. 

[(b)] (c) Integration by State.— As a condition of receipt of 
funds under this title, a State shall assure the Secretary that 
health support services funded under this title will be integrated 
with each other, that programs will be coordinated with other 
available programs (including Medicaid) and that the continuity of 
care and prevention services of individuals with HIV disease is en- 
hanced. 

[(c)] (d) Integration by Local or Private Entities.— As a con- 
dition of receipt of funds under this title, a local government or pri- 
vate nonprofit entity shall assure the Secretary that services fund- 
ed under this title will be integrated with each other, that pro- 
grams will be coordinated with other available programs (including 
Medicaid) and that the continuity of care and prevention services 
of individuals with HIV is enhanced. 

(e) Recommendations Regarding Release of Prisoners.— 
After consultation with the Attorney General and the Director of the 
Bureau of Prisons, with States, with eligible areas under part A, 
and with entities that receive amounts from grants under part A or 
B, the Secretary, consistent with the coordination required in sub- 
section (a), shall develop a plan for the medical case management 
of and the provision of support services to individuals who were 
Federal or State prisoners and had HIV disease as of the date on 
which the individuals were released from the custody of the penal 
system. The Secretary shall submit the plan to the Congress not 
later than two years after the date of the enactment of the Ryan 
White CARE Act Amendments of 2000. 

SEC. 2675B. AUDITS. 

For fiscal year 2002 and subsequent fiscal years, the Secretary 
may reduce the amounts of grants under this title to a State or po- 
litical subdivision of a State for a fiscal year if, with respect to such 
grants for the second preceding fiscal year, the State or subdivision 
fails to prepare audits in accordance with the procedures of section 
7502 of title 31, United States Code. The Secretary shall annually 
select representative samples of such audits, prepare summaries of 
the selected audits, and submit the summaries to the Congress. 

SEC. 2675C. ADMINISTRATIVE SIMPLIFICATION REGARDING PARTS A 
ANDB. 

(a) Coordinated Disbursement.— After consultation with the 
States, with eligible areas under part A, and with entities that re- 
ceive amounts from grants under part A or B, the Secretary shall 
develop a plan for coordinating the disbursement of appropriations 
for grants under part A with the disbursement of appropriations for 
grants under part B in order to assist grantees and other recipients 



Ill 



of amounts from such grants in complying with the requirements of 
such parts. The Secretary shall submit the plan to the Congress not 
later than 18 months after the date of the enactment of the Ryan 
White CARE Act Amendments of 2000. Not later than two years 
after the date on which the plan is so submitted, the Secretary shall 
complete the implementation of the plan, notwithstanding any pro- 
vision of this title that is inconsistent with the plan. 

(b) Biennial Applications. —After consultation with the States, 
with eligible areas under part A, and with entities that receive 
amounts from grants under part A or B, the Secretary shall make 
a determination of whether the administration of parts A and B by 
the Secretary, and the efficiency of grantees under such parts in 
complying with the requirements of such parts, would be improved 
by requiring that applications for grants under such parts be sub- 
mitted biennially rather than annually. The Secretary shall submit 
such determination to the Congress not later than two years after 
the date of the enactment of the Ryan White CARE Act Amendments 
of 2000. 

(c) Application Simplification. -After consultation with the 
States, with eligible areas under part A, and with entities that re- 
ceive amounts from grants under part A or B, the Secretary shall 
develop a plan for simplifying the process for applications under 
parts A and B. The Secretary shall submit the plan to the Congress 
not later than 18 months after the date of the enactment of the Ryan 
White CARE Act Amendments of 2000. Not later than two years 
after the date on which the plan is so submitted, the Secretary shall 
complete the implementation of the plan, notwithstanding any pro- 
vision of this title that is inconsistent with the plan. 

[SEC. 2677. AUTHORIZATION OF APPROPRIATIONS. 

[(a) In General.— Subject to subsection (b), there are authorized 
to be appropriated to make grants under parts A and B, such sums 
as may be necessary for each of the fiscal years 1996 through 2000. 
[(b) Development of Methodology.— 

[(1) In general.— With respect to each of the fiscal years 
1997 through 2000, the Secretary shall develop and implement 
a methodology for adjusting the percentages allocated to part 
A and part B to account for grants to new eligible areas under 
part A and other relevant factors. Not later than July 1, 1996, 
the Secretary shall prepare and submit to the appropriate com- 
mittees of Congress a report regarding the findings with re- 
spect to the methodology developed under this paragraph. 

[(2) Failure to implement.— If the Secretary determines 
that such a methodology under paragraph (1) cannot be devel- 
oped, there are authorized to be appropriated— 

[(A) such sums as may be necessary to carry out part A 
for each of the fiscal years 1997 through 2000; and 

[(B) such sums as may be necessary to carry out part B 
for each of the fiscal years 1997 through 2000.] 
SEC. 2677. AUTHORIZATION OF APPROPRIATIONS. 

(a) Part A.— For the purpose of carrying out part A, there are au- 
thorized to be appropriated such sums as may be necessary for each 
of the fiscal years 2001 through 2005. 



112 

(b) Part B.—For the purpose of carrying out part B, there are au- 
thorized to be appropriated such sums as may be necessary for each 
of the fiscal years 2001 through 2005. 

******* 

PART F — DEMONSTRATION AND TRAINING 
Subpart II— AIDS Education and Training Centers 

SEC. 2692. HIV/AIDS COMMUNITIES, SCHOOLS, AND CENTERS. 

(a) Schools; Centers.— 

(1) In general.— The Secretary may make grants and enter 
into contracts to assist public and nonprofit private entities 
and schools and academic health science centers in meeting the 
costs of projects— 

(A) [training! to train health personnel, including prac- 
titioners in programs under this title and other community 
providers, in the diagnosis, treatment, and prevention of 
HIV disease, including the prevention of the perinatal 
transmission of the disease [and includingj, including 
measures for the prevention and treatment of opportun- 
istic infections, and including (as applicable to the type of 
health professional involved), prenatal and other gyneco- 
logical care for women with HIV disease; 

(B) to train the faculty of schools of, and graduate de- 
partments or programs of, medicine, nursing, osteopathic 
medicine, dentistry, public health, allied health, and men- 
tal health practice to teach health professions students to 
provide for the health care needs of individuals with HIV 
disease; [and] 

(C) to develop and disseminate curricula and resource 
materials relating to the care and treatment of individuals 
with such disease and the prevention of the disease among 
individuals who are at risk of contracting the disease [.]; 
and 

(D) to develop protocols for the medical care of women 
with HIV disease, including prenatal and other gyneco- 
logical care for such women. 

******* 

(b) Dental Schools.— 

[(1) In general.— The Secretary may make grants to assist 
dental schools and programs described in section 777(b)(4)(B) 
with respect to oral health care to patients with HIV disease.] 

(1) In general. — 

(A) Grants. — The Secretary may make grants to dental 
schools and programs described in subparagraph (B) to as- 
sist such schools and programs with respect to oral health 
care to patients with HIV disease. 

(B) Eligible applicants.— For purposes of this sub- 
section, the dental schools and programs referred to in this 
subparagraph are dental schools and programs that were 
described in section 777(b)(4)(B) as such section was in ef- 



113 

feet on the day before the date of enactment of the Health 
Professions Education Partnerships Act of 1998 (Public 
Law 105-392) and in addition dental hygiene programs 
that are accredited by the Commission on Dental Accredita- 
tion. 

(2) Application.— Each dental school or program described 
in section [777(b)(4)(B)] the section referred to in paragraph 
(1)(B) may annually submit an application documenting the 
unreimbursed costs of oral health care provided to patients 
with HIV disease by that school or hospital during the prior 
year. 

(5) Community-based care. -The Secretary may make 
grants to dental schools and programs described in paragraph 
(1)(B) that partner with community-based dentists to provide 
oral health care to patients with HIV disease in unserved areas. 
Such partnerships shall permit the training of dental students 
and residents and the participation of community dentists as 
adjunct faculty. 
(c) Authorization of Appropriations.— 

(1) Schools; centers.— For the purpose of grants under 
subsection (a), there are authorized to be appropriated such 
sums as may be necessary for each of the [fiscal years 1996 
through 2000] fiscal years 2001 through 2005. 

[(2) Dental schools.— For the purpose of grants under sub- 
section (b), there are authorized to be appropriated such sums 
as may be necessary for each of the fiscal years 1996 through 
2000.] 

(2) Dental schools. — 

(A) In general.— For the purpose of grants under para- 
graphs (1) through (4) of subsection (b), there are author- 
ized to be appropriated such sums as may be necessary for 
each of the fiscal years 2001 through 2005. 

(B) Community-based care.— For the purpose of grants 
under subsection (b)(5), there are authorized to be appro- 

'priated such sums as may be necessary for each of the fis- 
cal years 2001 through 2005. 

******* 



ADDITIONAL VIEWS 



While I support the overall goal of the Coburn-Waxman Ryan 
White CARE Act Amendments of 2000, H.R. 4807, I must take 
issue with one key provision of the bill, the "hold harmless" provi- 
sion for Title I Eligible Metropolitan Areas (EMAs). I herewith ex- 
press my strong objections to this provision and urge that it be 
modified. 

The original CARE Act legislation of 1990 included two factors 
in Title I formula grants: cumulative AIDS cases and "density." 
The "density factor" took into account the number of AIDS cases 
per 100,000 people in a given EMA. When the CARE Act was reau- 
thorized in 1996, the criteria for Title I formula grants were 
changed. A "ten year weighted case band," which gives greater 
"weight" to recently diagnosed AIDS cases on the theory that this 
information is more likely to measure "living AIDS cases," was sub- 
stituted for the count of cumulative AIDS cases and the density 
factor was eliminated entirely. These changes, particularly the re- 
moval of the density factor, necessitated the inclusion of a "hold 
harmless" provision to prevent EMAs from experiencing dramatic 
funding losses. 

Under current law, a Title I EMA can lose no more than one per- 
cent of its funding each year, allowing for a five percent loss over 
five years. H.R. 4807 would alter this dramatically by allowing an 
EMA to lose 25 percent of its funding over five years. The result 
will be a rapid decline among systems of care and reduced access 
to vital HIV/AIDS services. 

The Senate bill reauthorizing the CARE Act, S. 2301, alters the 
"hold harmless" provision to allow for a 10 percent reduction in 
funding for an EMA over five years, a doubling of the rate in the 
current law. The Senate provision allows for a reasonable re- 
directing of resources without undermining systems of care through 
huge funding losses. I urge the Conferees to adopt the Senate pro- 
vision when this bill goes to Conference. 

The 25 percent formula reduction included in H.R. 4807 is trou- 
bling for many reasons. The only EMA likely to experience the full 
25% reduction in funding is San Francisco, meaning that this 
change will directly impact my constituents. 



(114) 



115 



IMPACT OF HOLD HARMLESS PROVISIONS OF 
S. 2311 AND H.R. 4708 ON FUNDING FOR THE 
SAN FRANCISCO EMA 



$18,000,000 
$16,000,000 
$14,000,000 
$12,000,000 
$1 0X100 jOOO 



S2311 
H.R.47QS 



Year One Year Two Year Three Year Four YearFwe 
Authorization Y«ar 



116 



It has been stated that San Francisco receives "too much" money 
relative to the number of people living with HIV/AIDS. This is 
false. The AIDS epidemic is still a national crisis and no EMA, in- 
cluding San Francisco, receives enough CARE Act funding to meet 
all the needs of those living with HIV/AIDS. As more people with 
HIV live longer due to life-saving but expensive combination thera- 
pies, the strain on public health systems is increasing, not decreas- 
ing. Reducing an EMA's Title I funding by 25 percent would seri- 
ously destabilize systems of care in that community. 



117 



Title I Funding Comparison 
Formula Awards FY 1996-FY 2000 




-5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 



Changs In Formula Funding (percent change from FY 96-FY 00) 
Chart does not Include Las Vegas or Norfolk; these EMAs did not receive funding In FY 96 
Average change: increase of 36.25% 



118 



Title I Funding Comparison 1996-2000 
(Includes total Title I allocation) 




200% 



Increase in total Title I Funding (percent change from FY 96-FY 00) 
Chart does not include Las Vegas or Norfolk; these EMAs did not receive funding In FY 96 
Average increase: 53.65% 



119 



The ten year weighted case band that is used to allocate Title I 
formula funding seriously undercounts the number of people ac- 
cessing CARE Act services. As noted previously, a recently diag- 
nosed AIDS case is given greater "weight" under this formula. 
However, the use of highly active antiretroviral therapy has made 
this method of measurement far less accurate. Combination thera- 
pies have allowed many people with AIDS to live longer than 10 
years and prevented many with HIV from advancing to an AIDS 
diagnosis as quickly as in the past. As a result, more people than 
ever are utilizing CARE Act services but many of them aren't being 
counted in the current Title I formula methodology. The hold harm- 
less provision in H.R. 4807 would have the effect of punishing 
EMAs like San Francisco for effective intervention to care for and 
prolong the lives of those with HIV. 

Proponents of the 25 percent hold harmless provision have of- 
fered a per capita analysis of each EMA to show that San Francisco 
receives too much in CARE Act funds. This argument is misleading 
and obscures the fact that CARE Act funding is designed to sup- 
port public health systems in cities where large numbers of AIDS 
cases threaten the system with collapse and is not tied to individ- 
uals with AIDS. A per capita analysis ignores other relevant fac- 
tors as well, such as the wide variance in cost of care among geo- 
graphic areas, making direct comparison very difficult. Similarly, 
CARE Act services are accessed at varying rates in different areas. 

I support the reauthorization of the Ryan White CARE Act; how- 
ever, it's vital that the more moderate Senate position on the hold 
harmless issue be adopted in Conference and I urge my colleagues 
to do so. 

Anna G. Eshoo. 

O 



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