Part C: Continued
Part C Grapples with Sensitive Issues
The focus on testing and concerns about the ramifications of HIV status in areas such as employment and health insurance coverage led to provisions in the Title III section of the Ryan White CARE Act related to confidentiality and anonymous testing. Title III dealt with other sensitive public health and political issues as well, such as informed consent for HIV testing, the content of counseling for HIV testing, and prohibitions on HIV testing as a requirement for other health services.
Filling in the Gaps in Care
From the beginning, the Title III/Part C program sought to fill gaps in primary care by giving preference to sites in areas that lacked those services and sites located far from communities with an adequate level of HIV care. The program’s original home within HRSA’s Bureau of Primary Health Care reflects its central focus, which Congress strengthened in the 1996 reauthorization by including a mandate that 50 percent of funds be used for primary care services.
Reauthorizations Reflect Changing Needs
In the first reauthorization of the Ryan White CARE Act, Congress added a provision for small planning grants to help sites develop services and qualify for funding and gave preference to sites in rural or underserved communities.
In 2000, the planning grants were expanded to include larger capacity-development grants but continued to target those same communities. In the first year of the program, HRSA awarded 48 grants to 20 States as well as the District of Columbia and Puerto Rico.2 Recognizing the vital role that Title III providers played in rural and underserved communities, Congress also included language in 2000 giving funding preference for service dollars to agencies in those communities.
Power to Reach Isolated Populations
The power of Part C to increase access in more isolated locations is illustrated by a network of sites funded through the Fletcher Allen Health Care/University of Vermont College of Medicine. In addition to the central site at the university, the program has sites at three small hospitals around the State using the hospital’s infrastructures for billing and appointment scheduling. The clinics have on-site nurse practitioners and social workers, and doctors travel to the sites on a regular schedule.
By integrating the HIV/AIDS clinics into the hospital’s larger clinics at two of the three sites, the program addressed concerns about stigma while ensuring access to specialized providers. Originally funded through the Ryan White Program Special Projects of National Significance (SPNS), the project also illustrates the successful transition of the SPNS program to a sustainable funding stream, a key priority in the establishment of that program. “The SPNS and Title III funding in Vermont have been a godsend,” says Christopher Grace, who runs the program. “Without those funding streams, these clinics wouldn’t exist, particularly the three rural clinics, and I don’t know what those people would be doing or what their level of care would be.”3
Addressing Issues of Quality in HIV/AIDS Care
Program changes have been driven not only by the desire to increase access to services but also to improve the quality of those services. As treatment became more available and complex, a requirement was added to ensure that patients at funded sites received care consistent with federal treatment guidelines. “The treatment guidelines are an important component of maintaining a standard of care across the program,” says Henia Handler of Fenway Community Health in Boston. “Because Part C clinics are rooted in the communities they serve, they provide that care with the cultural competence necessary to best meet the needs of their patients.”4
BUILDING INFRASTRUCTURE for HIGH-QUALITY CARE
The Part C Planning and Capacity Development Grants Programs provide time-limited resources to help public and private nonprofit agencies lay the groundwork for high-quality HIV care. Planning grants were added in 1996 and capacity development grants in 2000 to increase the pool of HIV care providers in communities with limited or no access to care. Both programs focus on agencies in rural or urban underserved areas and in communities of color.
The 1-year planning grants help agencies conduct research and lay the groundwork for new programs. Activities may include
- conducting needs assessments,
- convening planning bodies of stakeholders and partners,
- researching and applying for grants, and
- negotiating linkages with other agencies.
Capacity development grants strengthen the infrastructure of agencies that are already providing HIV care or are planning to do so. Also limited to 1 year, the grants help agencies create management, financial, and quality improvement systems and support in the following areas:
- Strategic planning
- Cultural competency training
- Consumer involvement
- Purchase of clinical supplies and equipment.
Changes in Spending
Beginning with the 2006 reauthorization, Title III became Part C. As required in Parts A and B, Part C grantees had to spend 75 percent of their funds on core medical services. This change built on an earlier requirement, instituted in 1996, that at least half of Part C funds received by a grantee be directed toward HIV testing, diagnosis, and medical treatment. This requirement was maintained in the 2009 reauthorization.