Federally funded AIDS programs appear to be effective and well run, according to a study by the General Accounting Office ( GAO ) issued on March 23. The report, "Use of Ryan White CARE Act and Other Assistance Grant Funds," was requested by members of Congress in preparation for reauthorization of the programs.
"Ryan White programs, no more corrupt that any other federal program," said Terje Anderson with a laugh. The new executive director of the National Organization of People With AIDS ( NAPWA ) in fact believes that they are "a little bit less so than a lot of other big programs." That is in part because local planning councils and oversight are built into them to a greater extent than in most federal activities.
"I´m happily surprised to see how small the malfeasance really was," said New York advocate and lobbyist Gary Rose, "and GAO looked really hard." The major exception is Puerto Rico where several people have been convicted of massive corruption.
The federal government spent an estimated $10 billion on HIV/AIDS in fiscal year 1999, with $5.8 billion going for treatment, $2 billion for research, $1.4 billion for income and support, and $0.8 billion for prevention. Medicaid is the largest program, covering about half of all PWAs.
"Prevention is dead last in the list of our priorities," said Rep Tom Coburn, R—Okla., a physician and leader in calling for the GAO audit. "If the best care is prevention, our current federal prevention program is guilty of malpractice."
The conservative Coburn has clashed with many in the AIDS community with his push for mandatory partner notification. A white paper on his office website denigrates the effectiveness of condoms and needle—exchange programs in reducing the spread of HIV. He supported funding of programs that preach abstinence as the sole element of prevention education.
AIDS advocates met with Coburn´s staff March 24, for what Anderson described as "a constructive conversation."
The GAO found that current programs are shortchanging minorities and rural areas. Most AIDS advocates readily admit some truth to that, but also point out that the study was skewed. It focused on six states: Arizona, Georgia, Michigan, Texas, Virginia, and Washington. It did not include California or New York, which between them are home to about half of the nation´s PWAs.
Rose said that was "smart" because the big states are "mutant programs where people really are being cared for and the services are working fairly well." The GAO mandate was to examine problem areas.
Residents of rural communities often have to travel long distances to find specialized HIV care. But the issue is not simply one of money. A physician needs a significant caseload of patients in order to develop expertise in a disease and often a rural area does not have that patient population. Furthermore, some patients fear discrimination and prefer not to be treated in their immediate community.
The best predictors of state AIDS programs being in trouble are the quality of their Medicaid and high—risk insurance pool, says Anderson. It is important to spread out the burden of HIV across several healthcare programs, and some states do not do that very well.
Senators Jim Jeffords, R—Vt., and Ted Kennedy, D—Mass., are putting the final touches on a bill to reauthorize Ryan White for another five years. It likely will be reported out of committee in early April.
Issues are still being negotiate but changes for the AIDS Drug Assistance Program ( ADAP ) may include a set—aside of 2% of funds for redirection to state programs that are in trouble. About half of new Title II money may go into a pool to be allocated to areas hard hit by emerging epidemics. This tinkering would meet some of the concerns of states in trouble without completely rewriting distribution formulas.
There is no guarantee that Congress will complete legislation this year. Only about 75 working days remain on the calendar due to summer recess for the party national conventions and an early wrap up in September to campaign for reelection.
The Presidential Advisory Committee on HIV/AIDS met earlier in the week of March 20 with 16 new members. It was the first significant turnover since its creation and much time was spent integrating the new people into the group.
Ronald Dellums, who for 27 years represented Oakland, California in Congress, now serves as chairman.
Coburn has made the GAO report available on his internet website at www.house.gov/coburn/gao.pdf