| Document
Title: Use of Ryan White CARE Act Funds for Outreach Services
DATE:
May 16, 2002
TO: All
Ryan White CARE Act Grantees
Enclosed
is the HIV/AIDS Bureau policy describing the use of the Ryan
White CARE Act funds for outreach services. This policy reflects
the changes in the Ryan White CARE Act Amendments of 2000
and establishes new guidelines for allowable expenditures
for outreach services for all of the Titles, except for the
Special Projects of National Significance (SPNS) Program.
A separate
question and answer (Q & A) document on the Use of CARE
Act Funds for Outreach Services is included to assist CARE
Act grantees, and their planning bodies and contractors, in
developing effective implementation strategies in compliance
with the policy.
If you
have any questions regarding the content of the HAB Policy
Notice, please contact your project officer. Thank you for
your attention to this important matter.
/s/
Deborah
L. Parham, Ph.D., R.N.
Acting Associate Administrator
Enclosures
Health
Resources and Services Administration
HIV/AIDS
Bureau
Use of
Ryan White CARE Act Funds for Outreach Services
Introduction
This
policy reflects the provisions in the Ryan White Comprehensive
AIDS Resources Emergency Act (CARE ) Amendments of 2000, replaces
"Division of Service Systems (DSS) Program Policy Guidance
No. 3: Outreach, June 1, 2000" (formerly Policy No. 97-03,
March 31, 1997), and establishes new guidelines for allowable
expenditures for outreach services. The purpose of all Ryan
White CARE Act funds is to ensure that eligible HIV-infected
persons gain or maintain access to HIV-related care and treatment.
The new requirements give grantees increased flexibility in
providing outreach services that are designed to identify
persons at high risk for HIV, to bring HIV-infected persons
into care, and for the purpose of early treatment in order
to provide an array of early intervention and prevention services.
Outreach services include services to both HIV-infected persons
who know their status and are not in care and HIV-infected
persons who do not know their status and are not in care.
The policy applies to all Titles and programs of the CARE
Act, except for the Special Projects of National Significance
(SPNS) Program, due to its innovative nature and search for
better models of care.
Outreach
Services Prior to the Ryan White CARE Act Amendments of 2000
Prior
to the reauthorization of the CARE Act, Titles I to IV grantees
were allowed to use funds to pay for outreach services with
certain restrictions. As outlined in former DSS Program Policy
Guidance, Title I and Title II grantees could use CARE Act
funds for "outreach programs which have as their principal
purpose identifying people with HIV disease so that they become
aware of and may be enrolled in care and treatment services
and receive related support services that enable them to remain
in care." Titles I and II funds could not be used for
outreach programs "which exclusively promote[d] HIV counseling
and testing and/or which [had] as their purpose HIV prevention
education." The policy also stated that grantees could
not use funds for "broad-scope awareness activities about
HIV services which target the general public (poster campaigns
for display on public transit, TV or radio public service
announcements, etc.)."
Title
III and Title IV had similar allowances and restrictions on
the use of CARE Act funds for outreach services. According
to their respective program guidances, Title III and Title
IV grantees could use funds for outreach services to target
high-risk individuals, who knew their HIV status, or if they
did not know their HIV status, for counseling and testing
and ultimately to link these individuals into care (that is,
case finding). Grantees could not use funds for mass media
campaigns or HIV prevention education efforts that did not
include linking people into care, as described above. However,
unlike Title I and Title II grantees, Titles III and IV grantees
could use CARE Act funds to pay for counseling and testing
services.
Outreach
Services After the Ryan White CARE Act Amendments of 2000
On
October 20, 2000, the Ryan White CARE Act Amendments of 2000
(Public Law 106-345) were enacted. These amendments reauthorized
the CARE Act (Title XXVI of the Public Health Service Act)
through 2005. The goal of the Amendments was to ensure that
individuals living with HIV and AIDS receive health care and
related support services. During the reauthorization process,
the Congress paid close attention to significant changes in
the HIV/AIDS epidemic and treatments that occurred between
1995 and 2000. In 2000, the CDC estimated that there were
between 800,000 and 900,000 persons living with HIV disease
in the United States, with 40,000 new infections annually.
CDC found that only approximately one-third of those individuals
are in medical care, one-third know their HIV status but are
not in medical care, and one-third do not know their HIV status.
Early access to highly active antiretroviral therapy (HAART)
and other care modalities reduces morbidity and mortality
among persons living with HIV disease.
In 2002,
CDC updated these estimates and found 850,000 to 950,000 persons
are living with HIV/AIDS. The proportion of infected persons
who know their status is increasing. CDC found that about
75 percent (670,000) have been diagnosed but a large proportion,
approximately one-third, may not be receiving ongoing care.
CDC indicates these two groups, persons diagnosed and undiagnosed,
about 400,000 to 500,000 HIV-infected persons, may not have
been tested, not receiving treatment or both.
In response
to these and other trends, Congress placed a new emphasis
on identifying and referring people with HIV disease into
regular care and treatment, especially under Title I and II.
The primary goal of this new emphasis was to improve early
diagnosis of HIV and to enhance access to HIV care and treatment
for persons infected or at high risk for HIV infection. The
managers' statement that accompanied the CARE Act Amendments
stated that, "[the] intent is to ensure that EMAs and
States understand that outreach activities which are consistent
with early intervention services and necessary to implement
the linkage into care strategies, are appropriate uses of
Titles I and II funds." (The Managers' Statement of Explanation,
Congressional Record, October 5, 2000, pages H-8841 to 8844).
It was not the Managers' intent that such activities supplant
or duplicate activities such as case finding, surveillance
and social marketing campaigns currently funded and administered
by the CDC. Instead, the Managers' wanted to relay the urgency
of increasing the coordination between HIV prevention and
HIV care and treatment services.
New
Outreach Service Guidance for Grantees
All
CARE Act grantees, including Titles I and II grantees can
now use funds to pay for HIV counseling and testing, outreach,
and referral services. This policy clarifies what constitutes
eligible outreach services for all Titles. In the provision
of these services, grantees should target individuals who
already know their HIV status, but are not receiving treatment.
Vulnerable, high-risk HIV individuals who may or may not know
they are HIV positive are often hesitant to seek care for
various reasons (e.g., stigma, distrust of the health care
system, lack of insurance, providers who lack cultural competence,
etc.). Congress acknowledged the difficulties associated with
outreach and recruitment among these individuals. In support
of these efforts, the fiscal year 2001 appropriations to the
Title II AIDS Drug Assistance Program (ADAP) provided $7 million
to support targeted education and outreach to vulnerable communities,
including racial/ethnic minorities who are disproportionately
impacted by the HIV/AIDS epidemic.
The goal
of outreach services is to link individuals into care that
would ultimately result in ongoing primary care and increased
adherence to medication regimens. Outcome measures need to
be defined by grantees that reflect the goal to evaluate the
success of outreach activities. Even with the changes in the
CARE Act Amendments, it appears that broad activities such
as providing "leaflets at a subway stop" or "a
poster at a bus shelter" would not meet the intent of
the law. This policy would give CARE Act grantees flexibility
to target and identify individuals who may or may not know
their HIV status and are not in care, have not returned for
treatment services or do not adhere with treatment requirements.
Policy
for Use of Ryan White CARE Act Funds for Outreach Services
Federal
funds received under the Ryan White CARE Act, as established
by Title XXVI of the Public Health Service Act, may be used
for outreach activities which have as their principal purpose
targeting activities, under specific needs assessment-based
service categories, that can identify individuals with HIV
disease. This includes those who know their HIV status and
are not in care as well as those individuals whose HIV status
is unknown, so that they become aware of the availability
of HIV-related services and enroll in primary care, AIDS Drug
Assistance Programs, and support services that enable them
to remain in care.
Outreach
activities supported with CARE Act funds must be:
a. Planned
and delivered in coordination with State and local HIV prevention
outreach activities to avoid duplication of effort and to
address a specific service need category identified through
State and local needs assessment processes;
b. Directed
to populations known, through local epidemiological data or
through review of service data, to be at disproportionate
risk for HIV infection;
c. Conducted
in such a manner, (i.e., time of day, month, events, sites,
method, cultural appropriateness) among those known to have
delayed seeking care relative to other populations, etc.,
and continually reviewed and evaluated in order to maximize
the probability of reaching individuals infected with HIV
who do not know their serostatus or know their status but
are not actively in treatment;
d. Designed
to:
- Establish
and maintain an association with entities that have effective
contact with persons found to be disproportionately impacted
by HIV or disproportionately differ in local access to care,
e.g., prisons, homeless shelters, substance abuse treatment
centers, etc.
- Direct
individuals to early intervention services (EIS) or primary
care (HIV counseling and testing, diagnostic, and clinical
ongoing prevention counseling services with appropriate
providers of health and support services).
- Include
appropriately trained and experienced workers to deliver
the message when applicable.
e. Designed
to provide quantifiable outcome measures such as the number
of individuals reached of previously unknown HIV status who
now know they are positive, and/or the number of HIV positive
individuals not in care who are now in care; and
f. Determined
to be a priority service by Title I planning bodies and Title
II consortia or State planning bodies, and be necessary to
implement the EMA or State wide comprehensive plan and associated
strategies.
Funds
awarded under the CARE Act may not be used for outreach activities
that exclusively promote HIV prevention education. Broad scope
awareness activities that address the general public (poster
campaigns for display on public transit, billboards, TV or
radio announcements, etc.) may be funded provided that they
are targeted and contain HIV information with explicit and
clear links to health care services.
Outreach
activities should supplement, and not supplant, such activities
that are carried out with amounts appropriated under Section
317 of the Public Health Service Act, "Project Grants
for Preventive Health Services" administered by the CDC
or with other Federal, State or local funds.
The grantee
must ensure that Ryan White CARE Act funds remain the payer
of last resort.
Q & A on the Use of Ryan White CARE Act Funds for Outreach
Services
1.
What is an example of a targeted outreach service?
The
Ryan White Comprehensive AIDS Resources Emergency (CARE) Act
funds are intended for targeted outreach services to link
persons with HIV who may or may not know their HIV status
into care. Each grantee must determine who these persons are,
where it is most likely these targeted services will reach
intended individuals and result in them gaining access to,
or maintaining in, HIV-related medical care or treatment.
For example, a grantee could fund outreach workers to locate
persons who tested positive and were informed of their test
results but never returned for treatment. The grantee could
use local epidemiological data to target HIV infected women
with an appropriate media campaign that reaches this targeted
audience and also informs them of the location and hours of
a clinic in their area.
2.
Can CARE Act funds be used in place of funds currently being
used from local, State, and Federal agency for similar outreach
program efforts?
CARE
Act funds must be the payer of last resort. Funds used for
outreach service must be used to supplement but not supplant
funds currently used from local, State, and Federal agency
programs. Similar outreach program efforts are defined as
those efforts targeting persons with HIV who may or may not
know their HIV status and are not in care.
3.
If a grantee (or subgrantee) wants to begin an outreach effort
targeting persons with HIV who may or may not know their status
and are not in care, what must grantees have in place in order
to proceed?
While
HRSA/HAB policy does not specify all of the types of outreach
services that can be funded with CARE Act funds, grantees
and providers are responsible for utilizing Ryan White CARE
Act funds for outreach activities and plans that have been
approved in their grant award. Such plans, when submitted
by grantees to HRSA must include in their budget and narrative:
- funding
amount for outreach services;
- a
description of outreach activities to be conducted along
with a rationale for why these activities will identify
persons with HIV not in care; and
- supporting
data describing the need for such targeted outreach efforts.
In addition,
grantees must develop outcome measures that include what their
expected results are from such efforts.
3a.
What are some examples?
These
outcome measures are to be determined by the grantee. Here
are examples of these types of output or performance measures.
Grantees may also want to review the HRSA/HAB "Outcomes
Evaluation Technical Assistance Guides" located on the
Bureau's web site http://hab.hrsa.gov/tools/outcomeguides.htm.
An outcome indicator or measure are observable, measurable
data sets, that are used to track a program's success in reaching
desired outcomes such as changes in CD4 counts over time that
are used to track a program's success in reaching desired
outcomes. Client-level outcomes are results or benefits for
an individual client, including biological measures such as
improved CD4 count or viral load. System level outcomes are
results for all clients receiving services, such as reduced
morbidity or mortality rates. Outputs are measures of the
direct products or volume of program operations, such as the
number of service units that a program delivers. A primary
care example includes the number of clients served, CD4 and
viral load tests completed, or specialty care consultation
provided. For outreach, this measure may be tracking persons
who get into care as a result of outreach and monitoring their
clinical progress. Grantees must document achievements made
in identifying and bringing persons into care through such
outreach services.
4.
Can grantees combine HIV prevention outreach activities with
Ryan White CARE Act outreach activities?
HIV prevention
outreach services funded through CDC, states, localities,
and community based organizations are broader in scope, than
RWCA funded outreach activities. The difference is in the
scope, intent, and content of the message. CARE Act outreach
is targeted to reach persons with HIV who may or may not know
their HIV status and are not in care. CARE Act outreach services
should be planned and delivered in a manner that: 1) targets
outreach based on local needs assessment or epidemiologic
data, to specific populations that are known to be at high
risk or knowledgeable of their status, but not in care; and
2) establishes a "relationship or association" between
the person targeted for the outreach and a program able to
provide the service. While HIV broad based prevention outreach
services can be co-located or coordinated with Ryan White
CARE Act outreach programs, grantees' Ryan White CARE Act
outreach activities must establish separate outreach planning,
outcome measures, and financial accounting for their specific
outreach activity.
5.
The Ryan White CARE Act Amendments contained certain changes.
Explain how to coordinate with points of entry, and early
intervention services within my outreach activities under
RWCA?
Points of Entry:
The Ryan
White CARE Act Amendments of 2000 allow Title I and Title
II to fund outreach services to link persons with HIV disease
into care. This law also introduces language such as "key
points of entry" (such as emergency rooms, substance
abuse treatment programs, detoxification centers, adult and
juvenile detention facilities, sexually transmitted disease
clinics, HIV counseling and testing sites, mental health program
and homeless shelters) and "early intervention services"
(HIV counseling and testing, diagnostic, and clinical ongoing
prevention counseling services with appropriate providers
of health and support services) where persons with HIV disease
can be identified, referred, and maintained in health care
and related supportive services. Grantees should coordinate
outreach services such that they include key points of entry
as sites where targeted outreach activities are conducted.
Early
Intervention Services (EIS):
The grantee
can use outreach to identify and refer individuals to new
and existing early intervention services. Early intervention
services stress the importance of bringing persons into care
earlier in HIV disease progression. Outreach services are
aimed at 1) identifying persons with HIV who may or may not
know their status and are not in care; and 2) providing HIV
counseling and testing, diagnostic, and clinical ongoing prevention
counseling services with appropriate providers of health and
support services. These early intervention services are now
eligible for all Titles under the Ryan White CARE Act.
6.
Can grantees receive Technical Assistance (T/A) to implement
this policy?
Grantees
should discuss any outreach services T/A needs with their
Project Officer who can provide technical T/A directly or
determine if additional T/A is needed from other HRSA/HAB
sources. The outreach plan must meet CARE Act legislative
requirements and HRSA/HAB policy and guidance.
7.
If I wanted to launch an outreach activity targeting persons
with HIV who may or may not know their status and are not
in care, what should I take into account in my program and
other area providers?
CARE
Act funds should be used for outreach services that are carefully
planned by grantees to bring persons with HIV into care. The
implementation of this policy is intended to ensure grantees
carefully consider their outreach strategy before implementing
any outreach services. In planning a potential outreach activity,
the grantee should take into consideration the capacity of
their programs to handle the estimated or increase in new
clients. Grantees and providers are responsible for developing
plans in coordination with other programs such that these
programs know of the grantees effort to launch an outreach
activity.
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